Patient-Therapeut-Bindung bei Drogenabhängigen: Instrumentenvalidierung und Therapieevaluation

In der vorliegenden Arbeit wird zum einen ein Instrument zur Erfassung der Patient-Therapeut-Bindung validiert (Client Attachment to Therapist Scale, CATS; Mallinckrodt, Coble & Gantt, 1995), zum anderen werden Hypothesen zu den Zusammenhängen zwischen Selbstwirksamkeitserwartung, allgemeinem Bindungsstil, therapeutischer Beziehung (bzw. Therapiezufriedenheit), Patient-Therapeut-Bindung und Therapieerfolg bei Drogen-abhängigen in stationärer Postakutbehandlung überprüft. In die Instrumentenvalidierung (einwöchiger Retest) wurden 119 Patienten aus 2 Kliniken und 13 Experten einbezogen. Die Gütekriterien des Instrumentes fallen sehr zufriedenstellend aus. An der naturalistischen Therapieevaluationsstudie (Prä-, Prozess-, Post-Messung: T0, T1, T2) nahmen 365 Patienten und 27 Therapeuten aus 4 Kliniken teil. Insgesamt beendeten 44,1% der Patienten ihren stationären Aufenthalt planmäßig. Auf Patientenseite erweisen sich Alter und Hauptdiagnose, auf Therapeutenseite die praktizierte Therapierichtung als Therapieerfolgsprädiktoren. Selbstwirksamkeitserwartung, allgemeiner Bindungsstil, Patient-Therapeut-Bindung und Therapiezufriedenheit eignen sich nicht zur Prognose des Therapieerfolgs. Die zu T0 stark unterdurchschnittlich ausgeprägte Selbstwirksamkeits-erwartung steigert sich über den Interventionszeitraum, wobei sich ein Moderatoreffekt der Patient-Therapeut-Bindung beobachten lässt. Es liegt eine hohe Prävalenz unsicherer allgemeiner Bindungsstile vor, welche sich über den Therapiezeitraum nicht verändern. Die patientenseitige Zufriedenheit mit der Therapie steigt von T1 zu T2 an. Die Interrater-Konkordanz (Patient/Therapeut) zur Einschätzung der Patient-Therapeut-Bindung erhöht sich leicht von T1 zu T2. Im Gegensatz dazu wird die Therapiezufriedenheit von Patienten und Therapeuten zu beiden Messzeitpunkten sehr unterschiedlich beurteilt. Die guten Testgütekriterien der CATS sprechen für eine Überlegenheit dieses Instrumentes gegenüber der Skala zur Erfassung der Therapiezufriedenheit. Deshalb sollte die Patient-Therapeut-Bindung anhand dieses Instrumentes in weiteren Forschungsarbeiten an anderen Patientenkollektiven untersucht werden, um generalisierbare Aussagen zur Validität treffen zu können.

Family satisfaction with critical care: measurements and messages

PURPOSE OF REVIEW: Family satisfaction in the ICU reflects the extent to which perceived needs and expectations of family members of critically ill patients are met by healthcare professionals. Here, we present recently developed tools to assess family satisfaction, with a special focus on their psychometric properties. Assessing family satisfaction, however, is not of much use if it is not followed by interpretation of the results and, if needed, consecutive measures to improve care of the patients and their families, or improvement in communication and decision-making. Accordingly, this review will outline recent findings in this field. Finally, possible areas of future research are addressed. RECENT FINDINGS: To assess family satisfaction in the ICU, several domains deserve attention. They include, among others, care of the patient, counseling and emotional support of family members, information and decision-making. Overall, communication between physicians or nurses and members of the family remains a key topic, and there are many opportunities to improve. They include not only communication style, timing and appropriate wording but also, for example, assessments to see if information was adequately received and also understood. Whether unfulfilled needs of individual members of the family or of the family as a social system result in negative long-term sequels remains an open question. SUMMARY: Assessing and analyzing family satisfaction in the ICU ultimately will support healthcare professionals in their continuing effort to improve care of critically ill patients and their families.

Within-subject comparison of two rigid bar designs connecting two interforaminal implants: patients' satisfaction and prosthetic results

BACKGROUND: There is evidence for the superiority of two-implant overdentures over complete dentures in the mandible. Various anchorage devices were used to provide stability to overdentures. The aim of the present study was to compare two designs of a rigid bar connecting two mandibular implants. MATERIALS AND METHODS: Completely edentulous patients received a new denture in the maxilla and an implant-supported overdenture in the mandible. They were randomly allocated to two groups (A or B) with regard to the bar design. A standard U-shaped bar (Dolder bar) was used connecting the two implants in a straight line. For comparison, precision attachments were soldered distal to the bar copings. Group A started the study with the standard bar (S-bar), while group B started with the attachment-bar (A-bar). After 3 months, they had to answer a questionnaire (visual analogue scale [VAS]); then the bar design was changed in both groups. After a period of another 3 months, the patients had to answer the same questions; then they had the choice to keep their preferred bar. Now the study period was extended to another year of observation, and the patients answered again the same questionnaire. In vivo force measurements were carried out with both bar types at the end of the test periods. The prosthetic maintenance service carried out during the 6-month period was recorded for both bar types in both groups. Statistical analysis as performed with the SPSS statistical package (SPSS Inc., Chicago, IL, USA). RESULTS: Satisfaction was high in both groups. Group B, who had entered the study with the attachment bar, gave slightly better ratings to this type for four items, while in group A, no differences were found. At the end of the 6-month comparison period, all but one patient wished to continue to wear the attachment bar. Prosthetic service was equal in groups A and B, but the total number of interventions is significantly higher in the attachment bar. Force patterns of maximum biting were similar in both bar designs, but exhibited significantly higher axial forces in the attachment bar. CONCLUSIONS: Both bar designs provide good retention and functional comfort. High stability appears to be an important factor for the patients' satisfaction and oral comfort. Rigid retention results in a higher force impact and appears to evoke the need for the retightening of occlusal screws, resulting in more maintenance service.

Family satisfaction in the intensive care unit: what makes the difference?

PURPOSE: To assess family satisfaction in the ICU and to identify parameters for improvement. METHODS: Multicenter study in Swiss ICUs. Families were given a questionnaire covering overall satisfaction, satisfaction with care and satisfaction with information/decision-making. Demographic, medical and institutional data were gathered from patients, visitors and ICUs. RESULTS: A total of 996 questionnaires from family members were analyzed. Individual questions were assessed, and summary measures (range 0-100) were calculated, with higher scores indicating greater satisfaction. Summary score was 78 +/- 14 (mean +/- SD) for overall satisfaction, 79 +/- 14 for care and 77 +/- 15 for information/decision-making. In multivariable multilevel linear regression analyses, higher severity of illness was associated with higher satisfaction, while a higher patient:nurse ratio and written admission/discharge criteria were associated with lower overall satisfaction. Using performance-importance plots, items with high impact on overall satisfaction but low satisfaction were identified. They included: emotional support, providing understandable, complete, consistent information and coordination of care. CONCLUSIONS: Overall, proxies were satisfied with care and with information/decision-making. Still, several factors, such as emotional support, coordination of care and communication, are associated with poor satisfaction, suggesting the need for improvement. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00134-009-1611-4) contains supplementary material, which is available to authorized users.

Predictors of satisfaction with treatment decision, decision-making preferences, and main treatment goals in patients with advanced cancer

Purpose This study investigated satisfaction with treatment decision (SWTD), decision-making preferences (DMP), and main treatment goals, as well as evaluated factors that predict SWTD, in patients receiving palliative cancer treatment at a Swiss oncology network. Patients and methods Patients receiving a new line of palliative treatment completed a questionnaire 4–6 weeks after the treatment decision. Patient questionnaires were used to collect data on sociodemographics, SWTD (primary outcome measure), main treatment goal, DMP, health locus of control (HLoC), and several quality of life (QoL) domains. Predictors of SWTD (6 = worst; 30 = best) were evaluated by uni- and multivariate regression models. Results Of 480 participating patients in eight hospitals and two private practices, 445 completed all questions regarding the primary outcome measure. Forty-five percent of patients preferred shared, while 44 % preferred doctor-directed, decision-making. Median duration of consultation was 30 (range: 10–200) minutes. Overall, 73 % of patients reported high SWTD (≥24 points). In the univariate analyses, global and physical QoL, performance status, treatment goal, HLoC, prognosis, and duration of consultation were significant predictors of SWTD. In the multivariate analysis, the only significant predictor of SWTD was duration of consultation (p = 0.01). Most patients indicated hope for improvement (46 %), followed by hope for longer life (26 %) and better quality of life (23 %), as their main treatment goal. Conclusion Our results indicate that high SWTD can be achieved in most patients with a 30-min consultation. Determining the patient’s main treatment goal and DMP adds important information that should be considered before discussing a new line of palliative treatment.

Patient-rated Outcomes of Lumbar Fusion in Patients with Degenerative Disease of the Lumbar Spine: Does Age Matter?

Introduction: Current demographic changes are characterized by population aging, such that the surgical treatment of degenerative spine conditions in the elderly is gaining increasing relevance. However, there is a general reluctance to consider spinal fusion procedures in this patient age group due to the increased likelihood of complications. The aim of this study was to assess the patient-rated outcome and complication rates associated with lumbar fusion procedures in three different age groups. Methods: This was a retrospective analysis of prospectively collected data from consecutive patients who underwent first-time, one to three level posterior instrumented fusion between 2004 and 2011, due to degenerative disease of the lumbar spine. Data were obtained from our Spine Surgery Outcomes Database (linked to the International Spine Tango Register). Before surgery, patients completed the multidimensional Core Outcome Measures Index (COMI), and at 3 and 12 months after surgery they completed the COMI and rated the Global Treatment Outcome (GTO) and their satisfaction with care. Patients were divided into three groups according to their age: younger (≥50y <65y; n = 317), older (≥65y <80y; n = 350), and geriatric (≥ 80y; n = 40). Results: 707 consecutive patients were included. The preoperative comorbidity status differed significantly (p < 0.0001) between the age groups, with the highest scores in the geriatric group. General medical complications during surgery were lower in the younger age group (7%) than in the older (13.4%; p = 0.006) and geriatric groups (17.5%; p = 0.007). Duration of hospital stay was longer (p = 0.006) in the older group (10.8 ± 3.7 days) than the younger (10.0 ± 3.6 days) group. There were no significant group differences (p>0.05) for any of the COMI domains covering pain, function, symptom specific well-being, general quality of life, and social and work disability at either 3 months’ or 12 months’ follow-up. Similarly, there were no differences (p>0.05) between the age groups for GTO and patient-rated satisfaction at either follow-up. Conclusions: Preoperative comorbidity and general medical complications during lumbar fusion for degenerative disorders of the lumbar spine are both greater in geriatric patients than in younger patients. However, patient-rated outcome is as good in the elderly as it is in younger age groups. These data suggest that geriatric age per se is not a contraindication to instrumented fusion for lumbar degenerative disease.

Job satisfaction of Swiss general practitioners with and without proficiency certificate in homeopathy

Introduction: Job satisfaction and therefore wellbeing of physicians is an important issue in high quality and safety of health care provision. The role of additional qualification in complementary medicine (CM) for job satisfaction of general practitioners (GPs), however, has not been explored. This study compared job satisfaction of conventional and homeopathic Swiss GPs. Methods: Participants of the Swiss Family Doctors Conference 2013 and members of the Swiss Association of Homeopathic Physicians participated in the survey. They indicated the extent of job satisfaction on 17 questions covering patient care, work-related burden, income-prestige, personal rewards, and professional relations. Results: Data of n = 125 GPs with homeopathic proficiency certificate and data of n = 143 GPs without any proficiency certificate in CM were analyzed. Overall job satisfaction was high and did not differ between the groups. However, due to lower number of patients per day, homeopathic GPs reported higher satisfaction in relations with patients and with workload, and lower satisfaction with income and in relations with peers compared to conventional GPs. Controlling for further confounding variables (e.g. working hours per week, practice setting), homeopathic GPs reported less satisfaction with their income than their conventional colleagues. Conclusions: Longer consultation time and lower number of patients homeopathic GPs see per day, may allowthem to unfold a deeper and more satisfying relationship with their patients and to lessen the workload. However, this comes along with financial discontent compared to conventional GPs. Certification in homeopathy and increased consultation time, respectively, may represent a way to enhance GPs’ job satisfaction.

Patient-Rated Outcomes of Lumbar Fusion in Patients with Degenerative Disease of the Lumbar Spine: Does Age Matter?

STUDY DESIGN Single centre retrospective study of prospectively collected data, nested within the Eurospine Spine Tango data acquisition system. OBJECTIVE The aim of this study was to assess the patient-rated outcome and complication rates associated with lumbar fusion procedures in three different age groups. SUMMARY OF BACKGROUND DATA There is a general reluctance to consider spinal fusion procedures in elderly patients due to the increased likelihood of complications. METHODS Before and at 3, 12, and 24 months after surgery, patients completed the multidimensional Core Outcome Measures Index (COMI). At the 3-, 12-, and 24-month follow-ups they also rated the Global Treatment Outcome (GTO) and their satisfaction with care. Patients were divided into three age groups: younger (≥50y < 65y; n = 317), older (≥65y < 80y; n = 350), and geriatric (≥ 80y; n = 40). RESULTS 707 consecutive patients were included. The preoperative comorbidity status differed significantly (p < 0.0001) between the age groups, with the highest scores in the geriatric group. Medical complications during surgery were lower in the younger age group (7%) than in the older (13.4%; p = 0.006) and geriatric groups (17.5%; p = 0.007); surgical complications tended to be higher in the elderly group (younger, 6.3%; older, 6.0%; geriatric, 15.0%; p = 0.09). There were no significant group differences (p > 0.05) for the scores on any of the COMI domains, GTO, or patient-rated satisfaction at either 3-, 12-, and 24-months follow-up. CONCLUSIONS Despite greater comorbidity and complication rates in geriatric patients, the patient-rated outcome was as good in the elderly as it was in younger age groups up to two years after surgery. These data indicate that geriatric age needs careful consideration of associated risks but is not per se a contraindication for fusion for lumbar degenerative disease. LEVEL OF EVIDENCE 4.

Doctor-patient communication in the medical interaction: Context, implications, and practice

Effective communication; whether from an interpersonal, mass media, or global perspective, is a critical component in public health. It is an essential conduit in increasing public awareness of available health resources, potential health hazards and related disease prevention strategies, and in delivering better health care. Within this context, available literature asserts doctor-patient communication as central to healthcare delivery. It has been shown to affect patient health outcomes, satisfaction with care, adherence to treatment recommendations, and even understanding of medical information. While research supports the essential imperative of interventions aimed at teaching doctors and patients the communication skills necessary for a successful and meaningful medical interaction, most interventions to date, focus on teaching these communication skills to doctors and seem to rely, largely, on mass media for providing patients with the information needed to increase communication efficacy. This study sought to fill a significant gap in the doctor-patient communication literature by reviewing the context of the doctor-patient exchange in the medical interaction, the implications of this exchange in resulting care of the patient, and the potential improvements to practice through interventions aimed at improving the communication exchange. Closing with an evaluation of a patient-centered communication intervention, the “How to Talk to Your Doctor” (HTTTYD) program that combines previously identified optimal strategies for improving communication between doctors and patients, this study examined the patients’ perspective of their potential as better communicators in the medical interaction. ^ Specific Aims, Hypotheses or Questions (Aim I) To examine the context of health communication within a public health framework and its relation to health care delivery. (Aim II) To review doctor-patient communication as a central focus within health care delivery and the resulting implications to patient care. (Aim III) To assess the utility of interventions to improve doctor-patient communication. Specifically, to evaluate the effectiveness of a patient-centered community education intervention, the “How to Talk to Your Doctor” (HTTTYD) program, aimed at improving patient communication efficacy.^

Relationship between nurse leader emotional intelligence and registered nurse job satisfaction

Aim: To determine the relationship between nurse leader emotional intelligence and registered nurse job satisfaction. ^ Background: Nurse leaders influence the work environments of nurses working at the bedside. Nursing leadership plays an important role in fostering work environments that attract and retain nurses. ^ Methods: A non-experimental, predictive design study conducted in 5 hospitals evaluated relationships between 31 nurse leaders and 799 registered nurses. The nurse leaders were administered the MSCEIT and MBTI. The registered nurses participated in the 2010 NDNQI RN Job Satisfaction Survey. ^ Measurements and Results: The sample population completed two online instruments, the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Myers Brigg Trait Inventory (MBTI). Nurse leader demographic data was collected consisting of age, sex, race, educational level, certification status and years in the profession of nursing. The relationships among characteristics of the nurse leader and staff nurses were examined using regression analysis and stepwise deletion. The results from the MBTI were obtained electronically from CPP. Inc. and the results of MSCEIT were obtained electronically from MHS, Inc. The nurse leader response rate was 46% and the NDNQI RN Job Satisfaction response rate was 62%. The sample of 31 nurse leaders were 65 percent female and 67.7% were White, 12.9% Black, and 19.4% Hispanic. The most prevalent MBTI type was ESTJ (19.35%), followed by ENFJ and ISFJ (9.68% each). The nurse leader sample was primarily extroverts (n=20), sensing (n=18), thinking (n=16) and judging (n=19). The nurse leaders' overall MSCEIT scores ranged from 69 to 111 (implying a range from those who should consider development to competent) with a mean score of 89.84 (consider improvement). The nurse leaders scored highest in the MSCEIT Facilitating subscale with scores ranging from 69 to 121 (consider development to strength) and a mean score of 95.19 (low average score). The overall mean MSCEIT mean scores for the entire sample ranged from 89.90 to 95.19 (consider emotional intelligence improvement to low average score) Overall, staff nurse participants in the NDNQI RN Job Satisfaction Survey were moderately satisfied with the nurse leaders as noted by a mean t score of 55.03 of 60 and this score was consistent with the comparison hospitals that participated in the 2010 NDNQI RN Job Satisfaction Survey (American Nurses Association, 2010). Staff nurses gave nurse leaders a mean score of 4.50 for patient assignments appropriate, and rated a mean score of 4.35 and moderately agreeing to recommend the hospital to a friend. ^ Conclusions: Future research is needed to determine if there is a relationship between nurse leader emotional intelligence ability and registered nurse job satisfaction. Additional research is also needed to determine what to measure in regards to nurse leader emotional intelligence, ability or behavior. Another issue that emerged in the examination of EI is the moderating relationship between the nurse leaders span of control and staff nurse satisfaction on the NDNQI. ^

Patient-centered medical home technology effects on hypertension and diabetes control

Background: Hypertension and Diabetes is a public health and economic concern in the United States. The utilization of medical home concepts increases the receipt of preventive services, however, do they also increase adherence to treatments? This study examined the effect of patient-centered medical home technologies such as the electronic health record, clinical support system, and web-based care management in improving health outcomes related to hypertension and diabetes. Methods: A systematic review of the literature used a best evidence synthesis approach to address the general question " Do patient-centered medical home technologies have an effect of diabetes and hypertension treatment?" This was followed by an evaluation of specific examples of the technologies utilized such as computer-assisted recommendations and web-based care management provided by the patient's electronic health record. Ebsco host, Ovid host, and Google Scholar were the databases used to conduct the literature search. Results: The initial search identified over 25 studies based on content and quality that implemented technology interventions to improve communication between provider and patient. After further assessing the articles for risk of bias and study design, 13 randomized controlled studies were chosen. All of the studies chosen were conducted in various primary care settings in both private practices and hospitals between the years 2000 and 2007. The sample sizes of the studies ranged from 42 to 2924 participants. The mean age for all of the studies ranged from 56 to 71 years. The percent women in the studies ranged from one to 78 percent. Over one-third of the studies did not provide the racial composition of the participants. For the seven studies that did provide information about the ethnic composition, 64% of the intervention participants were White. All of the studies utilized some type of web-based or computer-based communication to manage hypertension or diabetes care. Findings on outcomes were mixed, with nine out of 13 studies showing no significant effect on outcomes examined, and four of the studies showing significant and positive impact on health outcomes related to hypertension or diabetes Conclusion: Although the technologies improved patient and provider satisfaction, the outcomes measures such as blood pressure control and glucose control were inconclusive. Further research is needed with diverse ethnic and SES population to investigate the role of patient-centered technologies on hypertension and diabetes control. Also, further research is needed to investigate the effects of innovative medical home technologies that can be used by both patients and providers to increase quality of communication concerning adherence to treatments.^

Evaluating Patient Education Materials about Radiation Therapy

Targeted treatment education for cancer patients has the potential to promote adjustment through assisting patients to participate in treatment decision making, comply with treatment regimens and cope more effectively with treatment side effects. A quasi-experimental longitudinal pre-test post-test and follow-up design was used to assess the effect of a patient education video about radiation therapy on patients' psychological distress, knowledge about radiation therapy, self-efficacy about coping with treatment and physical symptoms. Patients with head and neck (n = 26) and breast cancer (n = 66) were recruited into the study and allocated into control and intervention groups. No significant differences were found between the control and intervention groups on any of the outcome variables. However, patients in the intervention group reported high levels of satisfaction with the video and all reported that they would recommend the video to other patients preparing for radiation therapy. As well, 90% of patients in the intervention group reported that some or all of the information in the video was new to them. Education materials that have excellent face validity and that are well received by patients may fail to produce significant change using standard controlled study designs. Future research in this area may need to consider alternative paradigms for evaluating the helpfulness of such materials. (C) 2003 Elsevier Science Ireland Ltd. All rights reserved.

A feasibility study of email communication between the patient's family and the specialist burns team

We investigated whether the parents of burns patients could capture suitable clinical images with a digital camera and add the necessary text information to enable the paediatric burns team to provide follow-up care via email. Four families were involved in the study, each of whom sent regular email consultations for six months. The results were very encouraging. The burns team felt confident that the clinical information in 30 of the 32 email messages (94%) they received was accurate, although in I I of these 30 cases (37%) they stated that there was room for improvement (the quality was nonetheless adequate for clinical decision making). The study also showed that low-resolution images (average size 37 kByte) were satisfactory for diagnosis. Families were able to participate in the service without intensive training and support. The user survey showed that all four families found it easy and convenient to take the digital photographs and to participate in the study. The results suggest that the technique has potential as a low-cost telemedicine service in burns follow-up, and that it requires only modest investment in equipment, training and support.

Rehabilitation after total knee replacement via low-bandwidth telemedicine: the patient and therapist experience

After a total knee replacement, inadequate rehabilitation is associated with poor physical outcomes and a reduced longevity of the knee prosthesis. We have developed a low-bandwidth telemedicine system to enable rehabilitation services to be delivered directly to the home of patients in rural and remote areas. We have examined the experience of clinical physiotherapists and of 31 participants who received treatment via the system. High levels of satisfaction were reported by participants (mean responses >7 on a 10 cm visual analogue scale). The service was found to be effective, safe and easy to use, and it integrated well into current clinical practice. The study demonstrates the potential for delivering physiotherapy services via low-bandwidth Internet connections.

Evaluation of clinically relevant states in patient reported outcomes in knee and hip osteoarthritis: the patient acceptable symptom state

Background: The patient acceptable symptom state ( PASS) is the value beyond which patients can consider themselves well. This concept can help in interpreting results of clinical trials. Objective: To determine the PASS estimate for patients with knee and hip osteoarthritis (OA) by assessing pain, patient's global assessment of disease activity, and functional impairment. Methods: A 4 week prospective multicentre cohort study of 1362 outpatients with knee or hip OA was carried out. Data on assessment of pain and patient's global assessment of disease, measured on visual analogue scales, and functional impairment, measured on the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) function subscale, were collected at baseline and final visits. The patients assessed their satisfaction with their current state at the final visit. An anchoring method based on the patient's opinion was used. Results: For patients with knee and hip OA, the estimates of PASS were, respectively, 32.3 and 35.0 mm for pain, 32.0 and 34.6 mm for patient global assessment of disease activity, and 31.0 and 34.4 points for WOMAC function score. The PASS varied moderately across the tertiles of baseline scores but not across age, disease duration, or sex. Conclusion: The use of PASS in clinical trials would provide more meaningful results expressed as a proportion of patients in an acceptable symptom state.