Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design
Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design
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有效的患者与临床医生互动以改善精神病患者的治疗结果：混合方法设计
DOI：
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发表时间：
2017
期刊：
影响因子：
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通讯作者：
R. McCabe
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文献类型：
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作者：
S. Priebe;Eoin Golden;D. Kingdon;Serif Omer;Sophie Walsh;Kleomenis Katevas;P. McCrone;S. Eldridge;R. McCabe
背景在英国，至少有10万名精神分裂症患者接受社区精神卫生团队(CMHTs)的护理。这些患者定期与临床医生会面，临床医生对他们进行评估，让他们参与治疗并协调护理。由于这些例行会议通常不是由研究证据指导的，因此以前设计了一种新的干预措施，对话，以构建磋商结构。使用手持计算机，临床医生要求患者对八个生活领域和三个治疗方面的满意度进行评分，并指出每个领域是否需要额外的帮助，并以图形显示回答并与之前的评分进行比较。在一项欧洲多中心试验中，干预在一年内改善了患者的生活质量。目前的方案建立在这项研究的基础上，通过在英国进一步开发对话。研究问题(1)如何改进干预的实际程序，包括所使用的软件和用户界面的设计？(2)如何将面向资源的干预的要素纳入临床医生手册和培训计划，以进行新的、更广泛的“对话+”干预？(3)新的对话+干预在改善精神分裂症或相关障碍患者的治疗结果方面有多大的效果和成本效益？(4)患者和临床医生对新的对话+干预有什么看法？方法我们在平板电脑上为NHS的CMHTs制作了新的软件，通过分析原始试验和18名精神病患者的6个焦点小组的对话视频来获得信息。我们在咨询专家后开发了新的“对话+”干预措施，在回应患者评级时纳入了以解决方案为重点的治疗原则，并在临床医生手册和培训计划中指定了治疗程序。我们对东伦敦NHS基金会托拉斯的49名临床医生和179名精神病患者进行了一项探索性的整群随机对照试验，将DIALOG+与主动对照进行了比较。在CMHTs中担任护理协调员的临床医生(与他们的患者)被随机分为1：1组，即DIALOG+组或照常治疗加积极对照组，以防止污染。干预和对照按月进行，为期6个月，数据收集在基线以及随机分组后的3、6和12个月。主要结果是在曼彻斯特生活质量短期评估中测量的主观生活质量；次要结果也被测量。我们还使用客户服务收据清单中的数据建立了对话干预的成本效益，客户服务收据清单记录了患者在每个时间点之前的3个月内使用医疗和社会护理服务(包括医院服务、门诊服务和药物)的回顾报告。患者病历中的临床记录补充了数据，以提高准确性。我们对16个视频对话+会议进行了探索性主题分析，并使用专门开发的坚持度量表测量了这些视频中的坚持度。我们对患者(n=19)和临床医生(n=19)进行焦点小组调查，了解他们的干预经验，并进行专题分析。我们发布了调查结果，并免费提供了应用程序(APP)、手册和培训，并制定了最终试验的方案。结果接受新干预的患者在3个月后(有效值：Cohen‘s d=0.34)、6个月后(Cohen’s d=0.29)和12个月后(Cohen‘s d=0.34)的生活质量明显好于DIALOG+组。对录像对话+会议的分析显示，实施情况不一致，坚持干预的比例略高于可能得分的一半。来自试验的DIALOG+ARM的患者和临床医生报告了许多积极的干预经验，包括更好的自我表达和提高的会议效率。报告的干预困难通过进一步完善对话+手册和培训得到解决。成本效益分析发现，干预既改善了结果又节省了成本的可能性为72%。局限性这项研究仅在伦敦东部城区进行，这意味着研究结果可能不能广泛推广到其他环境中。结论(1)尽管服务机构可能会根据现有证据考虑采用DIALOG+，但似乎有必要进行最终试验；(2)可以考虑将DIALOG+应用于有其他精神障碍的患者组，以及有身体健康问题的组；(3)更灵活地使用可变间隔可能有助于使干预更容易被接受和有效；(4)需要进行更多的过程评估，以确定干预组在试验中看到的改善确切涉及哪些机制；以及(5)似乎使DIALOG+有效的是它不是单独的治疗，也不是由专家管理的技术；相反，它改变和利用CMHTs中患者和临床医生之间现有的治疗关系，以启动积极的变化，帮助患者提高他们的生活质量。未来的研究未来的研究应该包括一项关于DIALOG+的明确试验，并测试对其他人群的干预效果，例如抑郁症患者。试验登记当前对照试验ISRCTN34757603。资助国家卫生研究所应用研究计划补助金计划。
Background At least 100,000 patients with schizophrenia receive care from community mental health teams (CMHTs) in England. These patients have regular meetings with clinicians, who assess them, engage them in treatment and co-ordinate care. As these routine meetings are not commonly guided by research evidence, a new intervention, DIALOG, was previously designed to structure consultations. Using a hand-held computer, clinicians asked patients to rate their satisfaction with eight life domains and three treatment aspects, and to indicate whether or not additional help was needed in each area, with responses being graphically displayed and compared with previous ratings. In a European multicentre trial, the intervention improved patients’ quality of life over a 1-year period. The current programme builds on this research by further developing DIALOG in the UK. Research questions (1) How can the practical procedure of the intervention be improved, including the software used and the design of the user interface? (2) How can elements of resource-oriented interventions be incorporated into a clinician manual and training programme for a new, more extensive ‘DIALOG+’ intervention? (3) How effective and cost-effective is the new DIALOG+ intervention in improving treatment outcomes for patients with schizophrenia or a related disorder? (4) What are the views of patients and clinicians regarding the new DIALOG+ intervention? Methods We produced new software on a tablet computer for CMHTs in the NHS, informed by analysis of videos of DIALOG sessions from the original trial and six focus groups with 18 patients with psychosis. We developed the new ‘DIALOG+’ intervention in consultation with experts, incorporating principles of solution-focused therapy when responding to patients’ ratings and specifying the procedure in a manual and training programme for clinicians. We conducted an exploratory cluster randomised controlled trial with 49 clinicians and 179 patients with psychosis in East London NHS Foundation Trust, comparing DIALOG+ with an active control. Clinicians working as care co-ordinators in CMHTs (along with their patients) were cluster randomised 1 : 1 to either DIALOG+ or treatment as usual plus an active control, to prevent contamination. Intervention and control were to be administered monthly for 6 months, with data collected at baseline and at 3, 6 and 12 months following randomisation. The primary outcome was subjective quality of life as measured on the Manchester Short Assessment of Quality of Life; secondary outcomes were also measured. We also established the cost-effectiveness of the DIALOG intervention using data from the Client Service Receipt Inventory, which records patients’ retrospective reports of using health- and social-care services, including hospital services, outpatient services and medication, in the 3 months prior to each time point. Data were supplemented by the clinical notes in patients’ medical records to improve accuracy. We conducted an exploratory thematic analysis of 16 video-recorded DIALOG+ sessions and measured adherence in these videos using a specially developed adherence scale. We conducted focus groups with patients (n = 19) and clinicians (n = 19) about their experiences of the intervention, and conducted thematic analyses. We disseminated the findings and made the application (app), manual and training freely available, as well as producing a protocol for a definitive trial. Results Patients receiving the new intervention showed more favourable quality of life in the DIALOG+ group after 3 months (effect size: Cohen’s d = 0.34), after 6 months (Cohen’s d = 0.29) and after 12 months (Cohen’s d = 0.34). An analysis of video-recorded DIALOG+ sessions showed inconsistent implementation, with adherence to the intervention being a little over half of the possible score. Patients and clinicians from the DIALOG+ arm of the trial reported many positive experiences with the intervention, including better self-expression and improved efficiency of meetings. Difficulties reported with the intervention were addressed by further refining the DIALOG+ manual and training. Cost-effectiveness analyses found a 72% likelihood that the intervention both improved outcomes and saved costs. Limitations The research was conducted solely in urban east London, meaning that the results may not be broadly generalisable to other settings. Conclusions (1) Although services might consider adopting DIALOG+ based on the existing evidence, a definitive trial appears warranted; (2) applying DIALOG+ to patient groups with other mental disorders may be considered, and to groups with physical health problems; (3) a more flexible use with variable intervals might help to make the intervention even more acceptable and effective; (4) more process evaluation is required to identify what mechanisms precisely are involved in the improvements seen in the intervention group in the trial; and (5) what appears to make DIALOG+ effective is that it is not a separate treatment and not a technology that is administered by a specialist; rather, it changes and utilises the existing therapeutic relationship between patients and clinicians in CMHTs to initiate positive change, helping the patients to improve their quality of life. Future research Future studies should include a definitive trial on DIALOG+ and test the effectiveness of the intervention with other populations, such as people with depression. Trial registration Current Controlled Trials ISRCTN34757603. Funding The National Institute for Health Research Programme Grants for Applied Research programme.
影响因子：
1.6
作者：
Nguyen, T D;Attkisson, C C;Stegner, B L
通讯作者：
Stegner, B L