Predictors of treatment outcomes. Patients with persistent physical symptoms in primary care.

BACKGROUND: Persistent physical symptoms (PSS) are consistently prevalent among primary care patients. PSS can negatively affect quality of life, healthcare costs, and work participation. AIM: To examine predictors of treatment outcome in patients with who received treatment by a work-focused communication tool known as the Individual Challenge Inventory Tool (ICIT) delivered by the patient's general practitioner. In a previous study we found substantially improved outcomes and reduced sick leave for patients treated by the work-focused communication tool ICIT compared to a control group. DESIGN & SETTING: This study is based on the findings of our previous cluster randomised controlled trial. METHOD: Regression analyses of the intervention group were used to identify predictors (all measured at baseline) of improvements in Patient Global Impression of Change (PGIC) and sick leave after 11 weeks follow up. RESULTS: Living alone predicted improvement in the adjusted model (OR =4·03, 95% CI: 1·33-12·25, P=0·014). Receiving long term benefits predicted improved PGIC in both the unadjusted (OR =2·30, 95% CI: 1·21-4·39, P=0·011) and adjusted models (OR =2·46, 95% CI: 1·04-5·83, P=0·040). In addition, living alone predicted reduced sick leave in the adjusted model (OR =3·23, 95% CI: 1·11-9·42, P=0·032. CONCLUSION: In general, there were few factors to predict the outcome of the work-focused communication tool ICIT. We therefore suggest that this work-focused communication tool ICIT is applicable to most patients with PPS. GPs may consider using the ICIT for all primary care patients who exhibit ineffective coping strategies in their daily lives and work, especially those who live alone.

The effects of a structured communication tool in patients with medically unexplained physical symptoms: a cluster randomized trial.

Background: Medically Unexplained Physical Symptoms (MUPS) are prevalent among primary care patients and frequently lead to diminished quality of life, increased healthcare costs, and decreased work participation. We aimed to examine the effects of a work-focused structured communication tool based on cognitive-behavioral therapy in patients with MUPS. Methods: In a Norwegian two-arm cluster randomized trial, the effectiveness of the structured communication tool Individual Challenge Inventory Tool (ICIT) was compared to usual care for patients with MUPS using a two-arm cluster randomized design. Enrollment period was between March 7 and April 1, 2022. Ten groups (clusters) of 103 General Practitioners (GPs) were randomized to provide the ICIT or usual care for 11 weeks. Patients received two or more sessions with their GP, and outcomes were assessed individually. Primary outcome was patient-reported change in function, symptoms, and quality of life measured by the Patient Global Impression of Change (PGIC). Secondary outcomes included sick leave, work-related self-efficacy (RTW-SE), health-related quality of life (RAND-36), and patient experiences with consultants (PEQ). The trial was registered on ClinicalTrials.gov (NCT05128019). Findings: A total of 541 patients with MUPS were enrolled in the study. In the intervention group 76% (n = 223) showed a significant overall improvement in function, symptoms, and quality of life as measured by the PGIC, compared to 38% (n = 236) in the usual care group (mean difference -0.8 ([95% CI -1.0 to -0.6]; p < 0.0001). At 11 weeks, the intervention group had a 27-percentage point decrease in sick leave (from 52.0 to 25.2), compared to 4-percentage point decrease (from 49.7 to 45.7) in the usual care group. Furthermore, compared to usual care, the intervention group reported significant improvements in work-related self-efficacy, health-related quality of life, and greater satisfaction with the communication during the consultations. No adverse events were reported. Interpretation: The implementation of the structured communication tool ICIT in primary care significantly improved patient outcomes and reduced sick leave among patients with MUPS. Funding: The study was funded by The Norwegian Research Fund for General Practice.

Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints.

OBJECTIVES: To explore GPs' considerations in decision-making regarding sick-listing of patients suffering from SHC. DESIGN: Qualitative analysis of data from nine focus-group interviews. SETTING: Three cities in different regions of Norway. Participants. A total of 48 GPs (31 men, 17 women; aged 32-65) participated. The GPs were recruited when invited to a course dealing with diagnostic practice and assessment of sickness certificates related to patients with composite SHCs. RESULTS: Decisions on sick-listing patients with SHCs were regarded as a very challenging task. Trust in the patient's own story and self-judgement was deemed crucial, but many GPs missed hard evidence of illness and loss of function. Several factors that might influence decision-making were identified: the patients' ability to present their story to evoke sympathy, the GP's prior knowledge of the patient, and the GPs' own experience as a patient and their tendency to avoid conflicts. The approach to the task of sick-listing differed from patient-led cooperation to resistant confrontation. CONCLUSION AND IMPLICATIONS: Issuing sickness certification in patients with composite health complaints is considered challenging and burdensome. It is seen as mainly patient-driven, and the decisions vary according to GPs' attitudes, beliefs, and personalities. Guiding the GPs to a more focused awareness of the decision process should be considered.