Attaining minimally disruptive medicine: context, challenges and a roadmap for implementation.

In this second of two papers on minimally disruptive medicine, we use the language of patient workload and patient capacity from the Cumulative Complexity Model to accomplish three tasks. First, we outline the current context in healthcare, comprised of contrasting problems: some people lack access to care and others receive too much care in an overmedicalised system, both of which reflect imbalances between patients' workloads and their capacity. Second, we identify and address five tensions and challenges between minimally disruptive medicine, the existing context, and other approaches to accessible and patient-centred care such as evidence-based medicine and greater patient engagement. Third, we outline a roadmap of three strategies toward implementing minimally disruptive medicine in practice, including large-scale paradigm shifts, mid-level add-ons to existing reform efforts, and a modular strategy using an existing 'toolkit' that is more limited in scope, but can fit into existing healthcare systems.

Randomised preference trial of medical versus surgical termination of pregnancy less than 14 weeks' gestation (TOPS).

OBJECTIVES: To determine the acceptability, efficacy and costs of medical termination of pregnancy (MTOP) compared with surgical termination of pregnancy (STOP) at less than 14 weeks' gestation, and to understand women's decision-making processes and experiences when accessing the termination service. DESIGN: A partially randomised preference trial and economic evaluation with follow-up at 2 weeks and 3 months. SETTING: The Royal Victoria Infirmary, Newcastle upon Tyne, UK. PARTICIPANTS: Women accepted for termination of pregnancy (TOP) under the relevant Acts of Parliament with pregnancies < 14 weeks' gestation on the day of abortion. A further group of women attending contraception and sexual health clinics participated in a discrete choice experiment (DCE). INTERVENTIONS: STOP: all women > or = 6 weeks' and < 14 weeks' gestation were primed with misoprostol 400 micrograms 2 hours before the procedure. STOP was performed under general anaesthesia using vacuum aspiration. MTOP: all women < 14 weeks' gestation were given mifepristone 200 milligrams orally, returning 36-48 hours later for misoprostol. OUTCOME MEASURES: Main outcome measure was acceptability of TOP method. Secondary outcome measures included strength of preference by willingness to pay (WTP); distress, using the Impact of Event Scale (IES); anxiety and depression; satisfaction with care; experience of care; frequency and extent of symptoms including self-assessment of pain; clinical effectiveness; and complications. A DCE was used to identify attributes that shape women's preferences for abortion services. RESULTS: The trial recruited 1877 women, 349 in the randomised arms and 1528 in the preference arms. Of those in the preference arms, 54% chose MTOP. At 2 weeks after the procedure more women having STOP would choose the same method again in the future. Acceptability of MTOP declined with increasing gestational age. The difference in acceptability between STOP and MTOP persisted at 3 months. At 2 weeks after TOP, women in the preference arms were prepared to pay more to have their preferred option. There was no difference in anxiety or depression scores in women having MTOP or STOP. However, women randomised to MTOP had higher scores on subscales of the IES at both 2 weeks and 3 months. There was no difference in IES scores between MTOP and STOP in the preference arm. Women were more likely to be satisfied overall and with technical and interpersonal aspects of care if they had STOP rather than MTOP. Experience of care scores were lower after MTOP in both randomised and preference arms. During admission women undergoing MTOP had more symptoms and reported higher mean pain scores, and after discharge reported more nausea and diarrhoea. There were no differences in time taken to return to work between groups; around 90% had returned to work and normal activity by 2 weeks. Rates of unplanned or emergency admissions were higher after MTOP than after STOP. Overall complication rates were also higher after MTOP, although this only achieved statistical significance in the preference arm. Overall, STOP cost more than MTOP due to higher inpatient standard costs. Even though complication rates were higher with MTOP, it was still more cost-effective. DCE identified three attributes with an almost equal impact on women's preferences: provision of counselling, number of days delay to the procedure, and possibility of an overnight stay. CONCLUSIONS: MTOP was associated with more negative experiences of care and lower acceptability. Acceptability of MTOP declined with increasing gestational age. MTOP was less costly but also less effective than STOP. The majority of women choosing MTOP were satisfied with their care and found the procedure acceptable. RECOMMENDATIONS FOR FURTHER RESEARCH: An audit of provision of MTOP and STOP in England and Wales is urgently required. Further studies exploring the barriers to offering women the choice of method of TOP are needed, together with research on the acceptability and effectiveness of (1) MTOP and manual VA in pregnancies below 9 weeks' gestation and (2) MTOP and dilatation and evacuation after 14 weeks' gestation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN07823656.

Qualitative methods in a randomised controlled trial: the role of an integrated qualitative process evaluation in providing evidence to discontinue the intervention in one arm of a trial of a decision support tool.

OBJECTIVE: To understand participants' experiences and understandings of the interventions in the trial of a computerised decision support tool in patients with atrial fibrillation being considered for anti-coagulation treatment. DESIGN: Qualitative process evaluation carried out alongside the trial: non-participant observation and semistructured interviews. PARTICIPANTS: 30 participants aged >60 years taking part in the trial of a computerised decision support tool. RESULTS: Qualitative evidence provided the rationale to undertake a decision to discontinue one arm of the trial on the basis that the intervention in that arm, a standard gamble values elicitation exercise was causing confusion and was unlikely to produce valid data on participant values. CONCLUSIONS: Qualitative methods used alongside a trial allow an understanding of the process and progress of a trial, and provide evidence to intervene in the trial if necessary, including evidence for the rationale to discontinue an intervention arm of the trial.

Teledermatology in the UK: lessons in service innovation.

BACKGROUND: Teledermatology has the potential to revolutionize the delivery of dermatology services by facilitating access to specialist services at a distance. In the U.K. over the previous decade there have been numerous attempts at introducing and using teledermatology; however, the development of teledermatology as routine service provision remains limited. OBJECTIVES: To identify factors that promote successful use of teledermatology as a part of routine service provision. METHODS: A longitudinal qualitative study of teledermatology, drawing on data from in-depth semistructured interviews; observations of systems in practice; and public meetings. Data were analysed collectively by the research team using established qualitative analytical techniques to identify key thematic categories. The sample consisted of teledermatology services within the U.K. (n = 12) studied over 8 years (1997-2005). Individual participants (n = 68 interviews) were consultant dermatologists, researchers, teledermatology nurses, administrators, patient advocates, general practitioners and technologists. RESULTS: The analysis compared services that did or did not become part of routine healthcare practice to identify features that supported the normalization of teledermatology. Requirements for using and integrating teledermatology into practice included: political support; perceived benefit and relative commitment that outweighs effort; pragmatic approaches to proving efficacy and safety; perception of risk as being 'manageable' on the basis of professional judgement; high levels of flexibility in practice (in terms of individuals, technology and organization); and reconceptualizing professional roles. CONCLUSIONS: Successful implementation of teledermatology as a routine service requires greater understanding of and attention to the interplay between social and technical aspects of teledermatology, and how this is accommodated both by healthcare professionals and the organizations in which they work.

Factors influencing the evaluation of telehealth interventions: preliminary results from a qualitative study of evaluation projects in the UK.

We have carried out a qualitative study of factors that influence the evaluation of telehealth. The study concerned six telehealth projects that are being tracked over two years. In the first 12 months of the study we carried out semistructured interviews and made observations of the participants in the projects. Each case study involved 5-15 subjects, many of whom were interviewed several times. The results indicate that important issues affecting telehealth evaluation include developing and maintaining the technology, reorganization of clinical and administrative duties, professional dynamics, and the difficulty of integrating service provision and evaluation. The findings suggest that the evaluation of telehealth interventions is highly complex, and that this complexity is often underestimated in the design and conduct of evaluation studies.

Management of venous thromboembolic disease in the lower limb.

Thromboembolic disease continues to cause significant morbidity and mortality in our community, despite extensive research into the aetiological factors and significant resources invested in the development of pharmacological agents for treating this condition. Development of more sensitive and specific modalities for identifying venous thromboses has improved their early detection, particularly in the commonest site, the lower limb. A rational evidence-based management pathway has not been formulated as debate continues over the most appropriate method of treatment. This review outlines the pathophysiology of the disease, provides a clinical pathway for the management of lower limb thromboembolic disease using reliable available evidence and briefly discusses the efficacy of drug therapy.

Patient satisfaction with teledermatology is related to perceived quality of life.

BACKGROUND: There is a lack of good data about patient satisfaction with teledermatology and about its potential interaction with quality-of-life factors. OBJECTIVES: To assess the association between perceived skin-related quality of life and patient satisfaction with a nurse-led teledermatology service. METHODS: In a mobile nurse-led teledermatology clinic located in four inner city general practices in Manchester, the teledermatology service used digital cameras to capture and store images of skin conditions for remote diagnosis by dermatologists. One hundred and twenty-three adult patients, non-urgent dermatology referrals from primary care, completed the Dermatology Life Quality Index (DLQI) and a 15-item patient satisfaction questionnaire. RESULTS: In common with other studies of patient satisfaction, subjects reported highly favourable views of 'hotel' aspects of the service (93%) and found it 'convenient' (86%). However, 40% of patients would have preferred to have had a conventional face-to-face consultation with a dermatologist, and 17% felt unable to speak freely about their condition. Patient satisfaction with the service was related to quality of life. Patients reporting lower quality of life as measured by the DLQI were more likely to prefer a face-to-face encounter with a dermatologist (r = 0.216, P < 0.05), and to evince anxiety about being photographed (r = 0.223, P < 0.05). CONCLUSIONS: Patient acceptance and satisfaction with telemedicine services is complicated by patients' subjective health status. Telehealthcare providers need to recognize that patients with poor quality of life may want and benefit from face-to-face interaction with expert clinicians.

Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature.

The objective of this study is to provide a systematic review of studies on patient satisfaction with telemedicine. The review included empirical studies that investigated patient satisfaction with that telemedicine service. The search strategy involved matching at least one of 11 'telemedicine' terms with one of 5 'satisfaction' terms. The following databases were searched: Telemedicine Information Exchange (TIE) database, MEDLINE, Science Citation Index (SCI), Social Science Citation Index (SSCI), Psycinfo, and Citation Index of Nursing and Allied Health (CINAHL). A highly structured instrument was used for data extraction. The review included 93 studies. Telepsychiatry represents the largest portion of these studies (25%), followed by multispecialty care (14%), nursing (11%), and dermatology (8%). Real-time videoconferencing was used in 88% of these studies. Only 19 (20%) included an independent control group, including 9 (10%) randomized control trial (RCT) studies. One third of studies were based on samples of less than 20 patients, and only 21% had samples of over 100 patients. Aspects of patient satisfaction most commonly assessed were: professional-patient interaction, the patient's feeling about the consultation, and technical aspects of the consultation. Only 33% of the studies included a measure of preference between telemedicine and face-to-face consultation. Almost half the studies measured only 1 or 2 dimensions of satisfaction. Reported levels of satisfaction with telemedicine are consistently greater than 80%, and frequently reported at 100%. Progression of telemedicine services from "trial" status to routine health service must be supported by improved research into patients' satisfaction with telemedicine. Further investigation of factors that influence patient acceptance of telemedicine is indicated.

Dealing with doubt. How patients account for non-specific chronic low back pain.

OBJECTIVE: To explore the ways that persons with long standing chronic low back pain respond to the problem of medical doubt about the presence of organic pathology. METHOD: Qualitative analysis of accounts provided by 12 persons attending a back pain rehabilitation clinic in NW England. RESULTS: Subjects rejected the notion that they were culpable for their pain. They were not culpable for the onset of their pain. They argued that despite their cooperation, no sensible explanation of their pain was forthcoming from health professionals. Finally, they asserted that medical scepticism had been damaging and dispiriting. CONCLUSION: Patients dealt with clinical doubt by stressing their own expertise. They constituted their beliefs about the cause and trajectory of their pain and disability as accurate accounts of their disability. They resisted the suggestion that there might be psychological factors involved in their ill-health by locating culpability among clinicians, who were confused or uncertain about diagnosis and treatment.

Psychiatry by videophone: a trial service in north west England.

In this paper we report on the use of a video link between two general practices and a hospital based mental health team in North West England to provide a trial telepsychiatry service for individuals with depression and anxiety related disorders. Patients (n = 16) took part in an evaluation of the service by both structured questionnaire and semi-structured interview. The results of the evaluation study suggest that patients may be highly critical of telemedicine systems and that they do so not simply on the grounds of the technical quality of video links, but also because the remote link increases the difficulty that the patient faces in expressing deep scated emotional and existential problems. It is not, therefore, simply a matter of technical quality in the link, but also a question of the quality of interpersonal relations perceived by the patient.

The benefits of back pain.

BACKGROUND: Chronic lower back pain (CLBP), without definable cause, is a symptom commonly presented to GPs, accounting for a significant proportion of their workload; it is also a common reason for sickness absence, and thus of national economic importance. OBJECTIVES: This qualitative study aims to explore how sufferers of CLBP describe their pain and its impact on their lives, and how their problem is dealt with in the consultation with their family doctor. METHOD: Semi-structured interviews were carried out with a sample of attenders at a back pain clinic set up in general practice. Transcription and analysis was carried out using a grounded-theory approach. RESULTS: Sufferers of CLBP describe withdrawal from normal social obligations, including work. They view their GP as being unable to help and, because of this, the doctor becomes a resource through which their social and economic inactivity can be legitimated. CONCLUSIONS: Presenting with CLBP permits the patient a good deal of power over the GP: it is difficult for the GP to challenge the patient's ideas without damaging the relationship. GPs are forced to collude with the patient's definition of ill-health, which may not be in the best interests of the patient or society.

The configuration of nurse-patient relationships: a critical view.

This paper sets out the grounds on which a reconfiguration of the ideas currently employed to conceptualize nurse-patient relationships might be founded. It is apparent that much of the rhetoric on which education for nursing practice is founded is difficult to relate to the realities of everyday nursing work. We explore the production of the nurse-patient relationship, in theory and practice as a therapeutic relationship. The paper moves beyond outlining yet again disparities between theory and practice. We argue that a more productive direction for research and analysis aims at understanding conditions that support sustained conduct characteristic of nursing practice in everyday work settings. We demonstrate some of the central conflicts operating between the professionalizing aims of nurses and the establishment of equitable positions for doing the work of nursing.

Patients' influence on doctors' behavior: a case study of patient strategies in somatization.

OBJECTIVE: Extensive empirical data and theory describe the inequality of power in relations between doctors and their patients. However, the focus has been on the ways in which doctors control the doctor-patient relationship. This has meant that the extent to which patients influence the consultation, and the ways in which they do this, have been neglected. METHODS: In this article, we use a single case to identify and illustrate distinct ways in which patients exert power to determine the outcome of consultations. CONCLUSION: This analysis leads to a more powerful explanation than is presently available to understand the somatization of psychological needs. According to this, the patient organizes strategies, which include the presentation of emotional and social distress, around a biomedical model. Because of their prior decisions as to their role, doctors permit themselves to be trapped in this model.

The attitudes of family physicians toward the peer review process.

We conducted a study to determine family physicians' attitudes and perceptions toward current peer review practices, and to discover if family physicians, general surgeons, and hospital-based physicians view the process differently. A survey instrument measured perceptions of physicians on the following four areas of the peer review process: (1) how peer reviews are administered, (2) the educational value of peer reviews, (3) the performance of peer review committees, and (4) the effect of the peer review process on physician morale. The survey was mailed to all 3528 practicing physicians who were members of a state medical society. A subgroup of 1695 family physicians, general surgeons, and hospital-based physicians was used for this study, of whom 774 (46%) responded to the questionnaire. Over one half of the family physicians responded negatively toward the peer review process on all items of the survey, with over 70% dissatisfied on five of the 17 items. Family physicians, general surgeons, and hospital-based physicians viewed the peer review process differently in the four areas measured. We found statistically significant differences of opinions regarding present peer review practices among the specialties cited. However, the overall dissatisfaction of the specialty groups studied may suggest that the concern resides more with the profession at large than with any one medical specialty group.

Hemophilia and extracorporeal shock wave lithotripsy: a case report.

We report renal calculi fragmentation in a hemophiliac patient through the use of extracorporeal shock wave lithotripsy. The Dornier Human Model III lithotriptor was used with the patient under general anesthesia and high frequency intermittent positive pressure ventilation was delivered via a Siemen-Elema 900-D Ventilator. The pathological features and clinical course are discussed.

Baclofen overdose.

Reported is a case of baclofen overdose in a 23-year-old woman. The patient manifested typical symptoms of baclofen overdose, including hypotonia, respiratory depression, and seizures. She was treated successfully with positive pressure ventilation, sedation, and intravenous antibiotics, and was discharged from the hospital on the 14th day following admission with no residual neurological signs, to be followed up in medical and psychiatric outpatient clinics. As baclofen becomes increasingly popular in the treatment of muscle spasm in certain neurological disorders, its availability for misuse increases.