Patient experience of telephone consultations in gynaecology: a service evaluation.

OBJECTIVE: To investigate patient perspective of telephone consultations (TCs) in gynaecology and identify which patients benefit most from a telemedicine system. DESIGN: Service evaluation. SETTING: Gynaecology outpatient services at a tertiary referral hospital. POPULATION: Patients who received a TC during May and June 2020. METHODS: Postal questionnaire combining three validated tools: QQ-10, Patient Enablement Index (PEI) and National Health Service Friends and Family Test (NHS-FFT). Quantitative data and free text responses were analysed. MAIN OUTCOME MEASURES: Responses to QQ-10, PEI and NHS-FFT. RESULTS: In total, 1307 patients were contacted and 504 patients responded (39%). Most (89%) described their experience as 'Very good' or 'Good' (NHS-FFT). Positive themes from responses included 'convenience', 'effectiveness' and 'equivalent care'. QQ-10 responses demonstrated a high Value score of 79 (0-100) and a low Burden score of 15. PEI scores suggested that most patients felt better or much better able to understand and cope with their condition following TC. The majority of patients (77%) would 'Strongly agree' or 'Mostly agree' to a repeat TC. Regarding patient outcomes, 21% were discharged and 71% required follow up. Menopause, fertility and endometriosis follow-up clinic patients benefited most from TC. Gynaecology-oncology patients found TC least acceptable. CONCLUSION: We report a large questionnaire survey of patient experience of TC in gynaecology. Telemedicine is convenient, acceptable and effective for conducting care in selected groups. TC can support patients in communicating intimate symptoms. TWEETABLE ABSTRACT: Telephone consultations are a convenient, acceptable and effective medium for conducting patient care in gynaecology.

Patient-reported experiences of consultation with an advanced nurse practitioner: Factor structure and reliability analysis of the patient enablement and satisfaction survey.

AIM: The aim was to analyse the psychometric properties of a patient-reported-experience measure, the Patient Enablement and Satisfaction Survey (PESS), when used to evaluate the care provided by Advanced Nurse Practitioners (ANPs) in terms of factor structure and internal consistency. The PESS is a 20-item, patient-completed data collection tool that was originally developed to measure patient experience and enablement following consultation with nurses in general practice. DESIGN: Cross-sectional survey; validity and reliability analysis. METHODS: The sample in this study consisted of 178 patients who consulted with 26 ANPs working in four different specialities. Data were collected between June and December 2019. An exploratory factor analysis of the PESS was conducted to determine convergent validity which was supported by parallel analysis and the traditional Kaiser criterion. The internal consistency of individual PESS items was determined via Cronbach's alpha, McDonald's omega, the Average Variance Extracted tests and item-subscale/total score correlations. RESULTS: A three-factor structure (PESS-ANP) was found through exploratory factor analysis and this was supported by parallel analysis, the traditional Kaiser criterion and the percentage of variance explained criterion. A high degree of internal consistency was reported across all factors. One question was omitted from the analysis ('Overall Satisfaction') following the identification of problematic cross-loadings. The three factor solution was identified as: patient satisfaction, quality of care provision and patient enablement. CONCLUSION: The findings of this study propose a three-factor model that is sufficiently reliable for analysing the experience and enablement of patients following consultation with an ANP. IMPACT: Increasingly, patient-reported experience measures are being used to evaluate patients' experience of receiving care from a healthcare professional. The PESS was identified to be reliable in evaluating the experience of patients who receive care from an ANP while a three-factor structure was proposed that can capture specific attributes of this care.

Patient enablement after a consultation with a general practitioner-Explaining variation between countries, practices and patients.

BACKGROUND: Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking. OBJECTIVE: To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement. DESIGN: We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated. SETTING AND PARTICIPANTS: A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data. RESULTS: In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported. DISCUSSION AND CONCLUSIONS: There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.

Comparison of the Patient Enablement Instrument (PEI) with two single-item measures among Finnish Health care centre patients.

BACKGROUND: The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients. METHODS: Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points. RESULTS: Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low. CONCLUSIONS: Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

Patient involvement in assessing consultation quality: validation of patient enablement instrument (PEI) in Lithuanian general practice.

BACKGROUND: The Patient Enablement Instrument (PEI) was designed to encapsulate consultation outcome from the perspective that increasing their understanding and coping ability would underpin a positive consultation outcome for patients. The objective of the study was the validation of the PEI in Lithuanian general practice and comparison of Lithuanian patients' enablement with previous studies in Europe to see if factors associated with patient enablement in Lithuania were reflective of those in the previous studies. METHODS: The Patient Enablement Instrument was translated into Lithuanian and included in the questionnaire along with the questions about a person's health, reasons for visiting the doctor and feeling about the consultation. Practices from 4 different municipalities that are situated in different geographical regions which have both town and rural areas were sampled randomly. Patients scheduled consecutively aged 18 years or more were the subjects of the study. The data analyses focused on internal reliability and concept validity. RESULTS: The overall mean patient enablement score was 6.43. Enablement scores declined with increasing patient age, and female patients were more enabled. Patients with biomedical problems had the highest enablement results, while patients with complex problems had the lower results. Enablement was positively related to receiving a prescription and knowing a doctor, and negatively related to wish having consultation with another doctor. CONCLUSIONS: This study substantiates the rationality of using PEI in assessing primary care consultations in Lithuania. The correlations of enablement largely reflect the situation in Western and Central Europe: longer consultation and access to the same physician increases patient enablement.

Developing a positive patient experience with nurses in general practice: An integrated model of patient satisfaction and enablement.

AIM: To develop a conceptual model that provides a comprehensive understanding of the structures and processes underpinning patient enablement and satisfaction in general practice nurse consultations. BACKGROUND: Current evidence regarding patient satisfaction and enablement arising from general practice nursing care is either quantitative or qualitative. To date, no studies have integrated the results of mixed methods research to provide a deeper understanding of processes that facilitate their achievement. DESIGN: A concurrent mixed methods study. METHODS: Our 2013-2014 concurrent mixed methods study comprised a quantitative study that analysed variables identified in interviews with general practice nurses, patients and practice managers with data from a cross-sectional survey of 678 patients receiving nursing care in 21 general practices; and a qualitative study that used a grounded theory approach to in-depth interviews with nurses and patients from these same practices. Using joint displays, we compared and integrated the results of the multilevel analyses and the grounded theory model derived from these studies. FINDINGS: We conceptualized a model-'developing a positive patient experience with nurses in general practice'-in which time, continuity of care, nursing scope of practice and autonomy, and patients' health conditions provide platforms for the processes of triggering healthcare partnerships and tailoring care in nurse consultations. CONCLUSION: This model builds on previous evidence describing processes and characteristics that optimize the quality of care in general practice nurse consultations. It provides a practical tool to inform education and training for general practice nurses and other clinicians.

Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings.

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.

The process of patient enablement in general practice nurse consultations: a grounded theory study.

AIM: The aim of this study was to gain insight into the process of patient enablement in general practice nursing consultations. BACKGROUND: Enhanced roles for general practice nurses may benefit patients through a range of mechanisms, one of which may be increasing patient enablement. In studies with general practitioners enhanced patient enablement has been associated with increases in self-efficacy and skill development. DESIGN: This study used a constructivist grounded theory design. METHODS: In-depth interviews were conducted with 16 general practice nurses and 23 patients from 21 general practices between September 2013 - March 2014. Data generation and analysis were conducted concurrently using constant comparative analysis and theoretical sampling focussing on the process and outcomes of patient enablement. Use of the storyline technique supported theoretical coding and integration of the data into a theoretical model. FINDINGS: A clearly defined social process that fostered and optimised patient enablement was constructed. The theory of 'developing enabling healthcare partnerships between nurses and patients in general practice' incorporates three stages: triggering enabling healthcare partnerships, tailoring care and the manifestation of patient enablement. Patient enablement was evidenced through: 1. Patients' understanding of their unique healthcare requirements informing their health seeking behaviours and choices; 2. Patients taking an increased lead in their partnership with a nurse and seeking choices in their care and 3. Patients getting health care that reflected their needs, preferences and goals. CONCLUSIONS: This theoretical model is in line with a patient-centred model of health care and is particularly suited to patients with chronic disease.

Patient-centredness in primary care walk-in clinics for refugees in Hamburg.

BACKGROUND: The huge increase of refugees to Germany caused a great challenge to the health system. We aimed to examine the level of patient-centredness in medical consultations with refugee patients, aided by video interpreters in primary care walk-in clinics (PCWC) in Hamburg. METHODS: Videotaped consultations (N = 92) of 83 patients from 2017 to 2018 were analysed. Two raters used the Measure of Patient-Centered Communication (MPCC) and the International Classification of primary care (ICPC-2). MPCC scores with regard to patients' reason for seeking medical care and the procedures taken were explored using variance analyses adjusted for age, gender, and the duration of the consultation. The duration was further explored by Pearson correlations. RESULTS: Patient-centredness of all consultations on average was 64% (95% CI 60-67) according to MPCC, with health-related issues affecting the results. The highest level of patient-centredness was achieved in psychological health issues with 79% (65-94), the lowest in respiratory ones with 55% (49-61). Longer consultations resulted in higher MPCC scores. CONCLUSIONS: The level of patient-centredness varied in the addressed health issues as well as in the duration of the consultation. Despite the variation, video interpreting in consultations supports a solid patient-centredness. PRACTICE IMPLICATIONS: We recommend the use of remote video interpreting services for outpatient healthcare to support patient-centred communication and to fill the gap of underrepresentation of qualified interpreters on site, regarding a high diversity of spoken languages.

Health Consumer Engagement, Enablement, and Empowerment in Smartphone-Enabled Home-Based Diagnostic Testing for Viral Infections: Mixed Methods Study.

BACKGROUND: Health consumers are increasingly taking a more substantial role in decision-making and self-care regarding their health. A range of digital technologies is available for laypeople to find, share, and generate health-related information that supports their health care processes. There is also innovation and interest in home testing enabled by smartphone technology (smartphone-supported home testing [smart HT]). However, few studies have focused on the process from initial engagement to acting on the test results, which involves multiple decisions. OBJECTIVE: This study aimed to identify and model the key factors leading to health consumers' engagement and enablement associated with smart HT. We also explored multiple levels of health care choices resulting from health consumer empowerment and activation from smart HT use. Understanding the factors and choices associated with engagement, enablement, empowerment, and activation helps both research and practice to support the intended and optimal use of smart HT. METHODS: This study reports the findings from 2 phases of a more extensive pilot study of smart HT for viral infection. In these 2 phases, we used mixed methods (semistructured interviews and surveys) to shed light on the situated complexities of health consumers making autonomous decisions to engage with, perform, and act on smart HT, supporting the diagnostic aspects of their health care. Interview (n=31) and survey (n=282) participants underwent smart HT testing for influenza in earlier pilot phases. The survey also extended the viral infection context to include questions related to potential smart HT use for SARS-CoV-2 diagnosis. RESULTS: Our resulting model revealed the smart HT engagement and enablement factors, as well as choices resulting from empowerment and activation. The model included factors leading to engagement, specifically various intrinsic and extrinsic influences. Moreover, the model included various enablement factors, including the quality of smart HT and the personal capacity to perform smart HT. The model also explores various choices resulting from empowerment and activation from the perspectives of various stakeholders (public vs private) and concerning different levels of impact (personal vs distant). CONCLUSIONS: The findings provide insight into the nuanced and complex ways health consumers make decisions to engage with and perform smart HT and how they may react to positive results in terms of public-private and personal-distant dimensions. Moreover, the study illuminates the role that providers and smart HT sources can play to better support digitally engaged health consumers in the smart HT decision process.

Factors affecting patient enablement in an Asian setting: a mixed methods study.

INTRODUCTION: Patient-centred medical care has been rising in importance since the turn of the century. It entails treating patients in relation to their biopsychosocial outlook so as to support the management of their conditions. The extent to which a patient is enabled to acquire skills and knowledge can be measured with the Patient Enablement Instrument (PEI) proposed by Howie and colleagues, and it has been noted to be more reflective of a good consultation compared to patient satisfaction scores. This study aimed to determine the level of patient enablement in the Singaporean context and the factors facilitating it. METHODS: We conducted an embedded mixed method study with primary care patients in two phases: (a) a PEI questionnaire was completed by 150 patients; and (b) a qualitative approach using focused group discussions and individual interviews was used to explore factors associated with high enablement. RESULTS: The mean PEI score was 4.5 ± 4.4, with significantly higher scores among patients attending specialised primary care clinics. Important physician factors were doctors' advice, attitude and relationship with the patient. Critical system factors included good continuity of care, workload and financial support, while patient factors included their beliefs, preparedness, inquisitiveness and trust, with considerable impact from the influence of community. CONCLUSION: The PEI score in the Singaporean context is similar to that of other Asian contexts, but slightly higher than that reported in Western studies. Good doctor-patient relationships, efficient systems facilitating continuity of care, and motivated and informed patients all contribute to increased enablement.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres.

BACKGROUND: The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility. RESULTS: The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period. CONCLUSIONS: The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Examining the Moderating Role of Patient Enablement on the Relationship Between Health Anxiety and Psychosomatic Distress: A Cross-Sectional Study at a Traditional Chinese Medicine Outpatient Clinic in Hong Kong.

BACKGROUND: Little research effort has been devoted to examining the role of patient enablement in alleviating health anxiety in primary care. In this study, we examined the role of patient enablement as a moderator in the relationship between health anxiety, psychological distress, and treatment seeking in traditional Chinese medicine (TCM). METHODS: The participants were 634 patients of a government-subsidized Chinese medicine outpatient clinic in Hong Kong. They were asked to complete a series of questionnaires on patient enablement, health anxiety, anxiety, depression, physical distress, annual clinic visits, and service satisfaction and provided various demographic details. Descriptive statistics, correlations, and general linear models were used to analyze the data. RESULTS: We found that patient enablement correlated positively with service satisfaction. Patient enablement also interacted significantly with health anxiety in affecting indices of psychological distress (depression, anxiety) and treatment seeking (annual visits). Among highly enabled patients, the positive association between health anxiety and indices of psychological distress was weakened, and they also showed more health anxiety-driven treatment seeking as measured by annual clinic visits. CONCLUSION: These findings suggest a moderating mechanism by which patient enablement weakens the relationship between health anxiety on psychological well-being and increases treatment-seeking behavior in TCM. Practitioners are encouraged to provide sufficient information to patients to foster self-care and disease self-management using complementary and alternative medicine (CAM).

PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version).

Background: The purpose of our study was to develop and psychometrically test a German-language survey instrument that measures patient enablement generically and in greater detail than previous instruments. Methods: A multidisciplinary team developed 13 items to capture individual aspects of patient enablement (PEN-13). A pre-test with 26 subjects was followed by a random sample survey of N = 1168 subjects. An exploratory factor analysis was conducted in a random split-half sample of the data to explore PEN-13's factor structure; a confirmatory factor analysis was conducted in the validation sample. The internal consistency of the factors was evaluated using Cronbach's alpha, PEN-13's construct validity was checked by means of additional hypothesis testing. Results: The two factors self-management and patient-practitioner interaction, detected in the exploratory analysis, were confirmed with a few modifications in the confirmatory factor analysis, with the comparative fit index (CFI) amounting to 0.903. The Cronbach's alpha values of those two factors amounted to α = 0.90 and α = 0.82, respectively. The correlations of the PEN-13 score with the 'general self-efficacy' and 'health literacy' (HLS-EU-Q16) scores further confirmed its construct validity; the respective correlation coefficients amounted to 0.57 and 0.60. Conclusion: The German version of the survey instrument Patient Enablement Scale-13 items (PEN-13) shows acceptable psychometric properties. Practical implications: PEN-13 seems particularly suitable for health services research purposes. We recommend checking the results in another sample as well as evaluating its responsiveness to enablement-enhancing interventions.

Nurse practitioner consultations in primary health care: an observational interaction analysis of social interactions and consultation outcomes.

OBJECTIVE: To determine the discrete nature of social interactions occurring in nurse practitioner consultations and investigate the relationship between consultation social interaction styles (biomedical and patient-centred) and the outcomes of patient satisfaction, patient enablement, and consultation time lengths. METHODS: A case study-based observational interaction analysis of verbal social interactions, arising from 30 primary health care nurse practitioner consultations, linked with questionnaire measures of patient satisfaction and enablement. RESULTS: A significant majority of observed social interactions used patient-centred communication styles (P=0.005), with neither nurse practitioners nor patients or carers being significantly more verbally dominant. Nurse practitioners guided the sequence of consultation interaction sequences, but patients actively participated through interactions such as asking questions. Usage of either patient-centred or biomedical interaction styles were not significantly associated with increased levels of patient satisfaction or patient enablement. The median consultation time length of 10.1 min (quartiles 8.2, 13.7) was not significantly extended by high levels of patient-centred interactions being used in the observed consultations. CONCLUSION: High usage levels of patient-centred interaction styles are not necessarily contingent upon having longer consultation times available, and clinicians can encourage patients to use participatory interactions, whilst still then retaining overall guidance of the phased sequences of consultations, and not concurrently extending consultation time lengths. This study adds to the body of nurse practitioner consultation communication research by providing a more detailed understanding of the nature of social interactions occurring in nurse practitioner consultations, linked to the outcomes of patient satisfaction and enablement.

Nurse practitioner consultations in primary health care: a case study-based survey of patients' pre-consultation expectations, and post-consultation satisfaction and enablement.

BACKGROUND: Research has not yet fully investigated links to consultation duration, patient expectations, satisfaction, and enablement in nurse practitioner consultations. This study was developed to address some of these research gaps in nurse practitioner consultations, particularly with a focus on expectations, satisfaction, and enablement. AIM: To explore the influence of pre-consultation expectations, and consultation time length durations on patient satisfaction and enablement in nurse practitioner consultations in primary health care. DESIGN: Survey component of a larger convergent parallel mixed methods case study designed to conjointly investigate the communication processes, social interactions, and measured outcomes of nurse practitioner consultations. The survey element of the case study focusses on investigating patients' pre-consultation expectations and post-consultation patient satisfaction and enablement. METHODS: A questionnaire measuring pre-consultation expectations, and post-consultation satisfaction and enablement, completed by a convenience sample of 71 adults consulting with nurse practitioners at a general practice clinic. Initial fieldwork took place in September 2011 to November 2012, with subsequent follow-up fieldwork in October 2016. RESULTS: Respondents were highly satisfied with their consultations and expressed significantly higher levels of enablement than have been seen in previous studies of enablement with other types of clinicians (P=0.003). A significant, small to moderate, positive correlation of 0.427 (P=0.005) between general satisfaction and enablement was noted. No significant correlation was seen between consultation time lengths and satisfaction or enablement. CONCLUSION: Higher levels of patient enablement and satisfaction are not necessarily determined by the time lengths of consultations, and how consultations are conducted may be more important than their time lengths for optimising patient satisfaction and enablement.

Structured postoperative physiotherapy in patients with cervical radiculopathy: 6-month outcomes of a randomized clinical trial.

OBJECTIVE Structured physiotherapy has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with cervical radiculopathy (CR), but randomized clinical trials to inform evidence-based clinical guidelines for the treatment of patients with CR after surgery are lacking. The aim of this study was to compare the results of structured postoperative physiotherapy combining neck-specific exercises with a behavioral approach to a standard postoperative approach in patients who had undergone surgery for cervical disc disease with CR at 6 months after surgery. METHODS Patients with cervical disc disease and persistent CR who were scheduled for surgery were randomized preoperatively to structured postoperative physiotherapy (n = 101) or a standard postoperative approach (n = 100). The latter included pragmatic physiotherapy in accordance with the usual Swedish postoperative care. Outcome measures included patient-reported neck disability as measured with the Neck Disability Index (NDI), intensity and frequency of neck and arm pain, global outcome of treatment, and expectation fulfillment, as well as enablement. RESULTS Patients who received structured postoperative physiotherapy reported greater expectation fulfillment (p = 0.01), and those who attended at least 50% of the treatment sessions reported less neck pain frequency (p = 0.05), greater expectation fulfillment (p = 0.001), and greater enablement (p = 0.04) compared with patients who received the standard postoperative approach. No other difference between treatment groups was found (p > 0.15). The NDI and neck and arm pain intensity were improved in both groups at 6 months after surgery (p < 0.001). Additional use of postoperative physiotherapy was reported by 61% of the patients who received the standard postoperative approach. CONCLUSIONS The results from this first randomized clinical trial of postoperative physiotherapy showed only minor additional benefit of structured postoperative physiotherapy compared with standard postoperative approach 6 months postoperatively in patients who underwent surgery for cervical disc disease with CR. Patients who received structured postoperative physiotherapy reported higher expectation fulfillment, and many patients in the standard postoperative approach group perceived a need for additional treatments after surgery, suggesting that patients with CR are in need of further postoperative support. The results confirm that neck-specific exercises are tolerated postoperatively by patients with CR, but more studies of postoperative physiotherapy are needed to inform clinical guidelines for this patient group. Clinical trial registration no.: NCT01547611 (clinicaltrials.gov).

A preconsultation web-based tool to generate an agenda for discussion in diabetes outpatient clinics to improve patient outcomes (DIAT): a feasibility study.

OBJECTIVE: To test the feasibility of running a randomised controlled trial of a preconsultation web-based intervention (Presenting Asking Checking Expressing (PACE-D)) to improve the quality of care and clinical outcomes in patients with diabetes. DESIGN AND SETTING: A feasibility study (with randomisation) conducted at outpatient diabetes clinics at two secondary care hospitals in Devon, UK. PARTICIPANTS: People with diabetes (type 1 and type 2) attending secondary care general diabetes outpatient clinics. INTERVENTION: The PACE-D, a web-based tool adapted for patients with diabetes to use before their consultation to generate an agenda of topics to discuss with their diabetologist. OUTCOMES: The percentage of eligible patients who were recruited and the percentage of participants for whom routine glycosylated haemoglobin (HbA1c) data (the putative primary outcome) could be extracted from medical notes and who completed secondary outcome assessments via questionnaire at follow-up were reported. RESULTS: In contrast with the planned recruitment of 120 participants, only 71 participants were randomised during the 7-month recruitment period. This comprised 18.7% (95% CI 14.9% to 23.0%) of those who were eligible. Mean (SD) age of the participants was 56.5 (12.4) years and 66.2% had type 1 diabetes. Thirty-eight patients were randomised to the intervention arm and 33 to the control arm. HbA1c data were available for only 73% (95% CI 61% to 83%) of participants at the 6 months follow-up. The questionnaire-based data were collected for 66% (95% CI 54% to 77%) of the participants at 6 months follow-up. Participants reported that the PACE-D tool was easy to use. CONCLUSIONS: A randomised controlled trial of the preconsultation web-based intervention as set out in our current protocol is not feasible without significant modification to improve recruitment and follow-up of participants. The study also provides insights into the feasibility and challenges of conducting complex intervention trials in everyday clinical practice. TRIAL REGISTRATION: ISRCTN75070242.

Patient Enablement After a Single Appointment With a GP: Analysis of Finnish QUALICOPC Data.

BACKGROUND: Patient enablement is described as patient's ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. METHODS: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. RESULTS: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant ( P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. CONCLUSIONS: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.

The impact of general practice nursing care on patient satisfaction and enablement in Australia: A mixed methods study.

BACKGROUND: The numbers of nurses in general practice in Australia tripled between 2004 and 2012. However, evidence on whether nursing care in general practice improves patient outcomes is scarce. Although patient satisfaction and enablement have been examined extensively as outcomes of general practitioner care, there is little research into these outcomes from nursing care in general practice. The aim of this study was to examine the relationships between specific general practice characteristics and nurse consultation characteristics, and patient satisfaction and enablement METHODS: A mixed methods study examined a cross-section of patients from 21 general practices in the Australian Capital Territory. The Patient Enablement and Satisfaction Survey was distributed to 1665 patients who received nursing care between September 2013 and March 2014. Grounded theory methods were used to analyse interviews with staff and patients from these same practices. An integrated analysis of data from both components was conducted using multilevel mixed effect models. RESULTS: Data from 678 completed patient surveys (response rate=42%) and 48 interviews with 16 nurses, 23 patients and 9 practice managers were analysed. Patients who had longer nurse consultations were more satisfied (OR=2.50, 95% CI: 1.43-4.35) and more enabled (OR=2.55, 95% CI: 1.45-4.50) than those who had shorter consultations. Patients who had continuity of care with the same general practice nurse were more satisfied (OR=2.31, 95% CI: 1.33-4.00) than those who consulted with a nurse they had never met before. Patients who attended practices where nurses worked with broad scopes of practice and high levels of autonomy were more satisfied (OR=1.76, 95% CI: 1.09-2.82) and more enabled (OR=2.56, 95% CI: 1.40-4.68) than patients who attended practices where nurses worked with narrow scopes of practice and low levels of autonomy. Patients who received nursing care for the management of chronic conditions (OR=2.64, 95% CI: 1.32-5.30) were more enabled than those receiving preventive health care. CONCLUSIONS: This study provides the first evidence of the importance of continuity of general practice nurse care, adequate time in general practice nurse consultations, and broad scopes of nursing practice and autonomy for patient satisfaction and enablement. The findings of this study provide evidence of the true value of enhanced nursing roles in general practice. They demonstrate that when the vision for improved coordination and multidisciplinary primary health care, including expanded roles of nurses, is implemented, high quality patient outcomes can be achieved.