Adina Abdullah

Unmet needs of patients with chronic obstructive pulmonary disease (COPD): a qualitative study on patients and doctors

BackgroundChronic Obstructive Pulmonary Disease (COPD) is a chronic disease with repeated exacerbations resulting in gradual debilitation. The quality of life has been shown to be poor in patients with COPD despite efforts to improve self-management. However, the evidence on the benefit of self-management in COPD is conflicting. Whether this could be due to other unmet needs of patients have not been investigated. Therefore, we aimed to explore unmet needs of patients from both patients and doctors managing COPD.MethodsWe conducted a qualitative study with doctors and patients in Malaysia. We used convenience sampling to recruit patients until data saturation. Eighteen patients and eighteen doctors consented and were interviewed using a semi-structured interview guide. The interviews were audio-recorded, transcribed verbatim and checked by the interviewers. Data were analysed using a thematic approach.ResultsThe themes were similar for both the patients and doctors. Three main themes emerged: knowledge and awareness of COPD, psychosocial and physical impact of COPD and the utility of self-management. Knowledge about COPD was generally poor. Patients were not familiar with the term chronic obstructive pulmonary disease or COPD. The word ‘asthma’ was used synonymously with COPD by both patients and doctors. Most patients experienced difficulties in their psychosocial and physical functions such as breathlessness, fear and helplessness. Most patients were not confident in self-managing their illness and prefer a more passive role with doctors directing their care.ConclusionsIn conclusion, our study showed that knowledge of COPD is generally poor. There was mislabelling of COPD as asthma by both patients and physicians. This could have resulted in the lack of understanding of treatment options, outcomes, and prognosis of COPD. The misconception that cough due to COPD was contagious, and breathlessness that resulted from COPD, had important physical and psychosocial impact, and could lead to social isolation. Most patients and physicians did not favour self-management approaches, suggesting innovations based on self-management may be of limited benefit.

The influence of self-owned home blood pressure monitoring (HBPM) on primary care patients with hypertension: A qualitative study

BackgroundHome blood pressure monitoring (HBPM) is gaining popularity among hypertensive patients. This study aimed to explore the influence of self-initiated HBPM on primary care patients with hypertension.MethodsSix in-depth interviews and two focus group discussions were conducted, taking into consideration the experiences of 24 primary care patients with hypertension. These patients had been using HBPM as part of their hypertension management. The overriding influences were grouped under themes which emerged from analyzing the data using the grounded theory approach.ResultsThere are both positive and negative influences of self-initiated HBPM. Patients used the readings of their HBPM to decide on many aspects of their hypertension management. The HBPM readings both influenced their adherence to diet and exercise and provided certain reassurance when they experienced symptoms. In addition, the act of discussing their HBPM readings with their health care providers resulted in an enhanced doctor-patient therapeutic relationship. Nevertheless, HBPM created confusion at times in some patients, particularly with regard to the target blood pressure level and the need for medication. This led to some patients making their own medical decisions based on their own standards.ConclusionsHBPM is becoming an integral part of hypertension management. Primary care patients who self-initiated HBPM reported being more self-efficacious, but lack of participation and guidance from their doctors created confusion, and hindered the true benefit of HBPM.

Healthcare Professionals’ and Policy Makers’ Views on Implementing a Clinical Practice Guideline of Hypertension Management: A Qualitative Study

Introduction Most studies have reported barriers to guideline usage mainly from doctors’ perspective; few have reported the perspective of other stakeholders. This study aimed to determine the views and barriers to adherence of a national clinical practice guideline (CPG) on management of hypertension from the perspectives of policymakers, doctors and allied healthcare professionals. Methods This study used a qualitative approach with purposive sampling. Seven in depth interviews and six focus group discussions were conducted with 35 healthcare professionals (policy makers, doctors, pharmacists and nurses) at a teaching hospital in Kuala Lumpur, Malaysia, between February and June 2013. All interviews were audio-recorded, transcribed verbatim and checked. Thematic approach was used to analyse the data. Results Two main themes and three sub-themes emerged from this study. The main themes were (1) variation in the use of CPG and (2) barriers to adherence to CPG. The three sub-themes for barriers were issues inherent to the CPG, systems and policy that is not supportive of CPG use, and attitudes and behaviour of stakeholders. The main users of the CPG were the primary care doctors. Pharmacists only partially use the guidelines, while nurses and policy makers were not using the CPG at all. Participants had suggested few strategies to improve usage and adherence to CPG. First, update the CPG regularly and keep its content simple with specific sections for allied health workers. Second, use technology to facilitate CPG accessibility and provide protected time for implementation of CPG recommendations. Third, incorporate local CPG in professional training, link CPG adherence to key performance indicators and provide incentives for its use. Conclusions Barriers to the use of CPG hypertension management span across all stakeholders. The development and implementation of CPG focused mainly on doctors with lack of involvement of other healthcare stakeholders. Guidelines should be made simple, current, reliable, accessible, inclusive of all stakeholders and with good policy support.

What influences patients’ acceptance of a blood pressure telemonitoring service in primary care? A qualitative study

Background Telemonitoring of home blood pressure (BP) is found to have a positive effect on BP control. Delivering a BP telemonitoring service in primary care offers primary care physicians an innovative approach toward management of their patients with hypertension. However, little is known about patients’ acceptance of such service in routine clinical care. Objective This study aimed to explore patients’ acceptance of a BP telemonitoring service delivered in primary care based on the technology acceptance model (TAM). Methods A qualitative study design was used. Primary care patients with uncontrolled office BP who fulfilled the inclusion criteria were enrolled into a BP telemonitoring service offered between the period August 2012 and September 2012. This service was delivered at an urban primary care clinic in Kuala Lumpur, Malaysia. Twenty patients used the BP telemonitoring service. Of these, 17 patients consented to share their views and experiences through five in-depth interviews and two focus group discussions. An interview guide was developed based on the TAM. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used for analysis. Results Patients found the BP telemonitoring service easy to use but struggled with the perceived usefulness of doing so. They expressed confusion in making sense of the monitored home BP readings. They often thought about the implications of these readings to their hypertension management and overall health. Patients wanted more feedback from their doctors and suggested improvement to the BP telemonitoring functionalities to improve interactions. Patients cited being involved in research as the main reason for their intention to use the service. They felt that patients with limited experience with the internet and information technology, who worked out of town, or who had an outdoor hobby would not be able to benefit from such a service. Conclusion Patients found BP telemonitoring service in primary care easy to use but needed help to interpret the meanings of monitored BP readings. Implementations of BP telemonitoring service must tackle these issues to maximize the patients’ acceptance of a BP telemonitoring service.

Community Palliative Care Nurses' Challenges and Coping Strategies on Delivering Home-Based Pediatric Palliative Care: A Qualitative Study.

Objective: The aim of this study was to explore the experience of community palliative care nurses providing home care to children. Method: A qualitative study was conducted at the 3 community palliative care provider organizations in greater Kuala Lumpur from August to October 2014. Data were collected with semistructured interviews with 16 nurses who have provided care to children and was analyzed using thematic analysis. Two categories were identified: (1) challenges nurses faced and (2) coping strategies. The themes identified from the categories are (1) communication challenges, (2) inadequate training and knowledge, (3) personal suffering, (4) challenges of the system, (5) intrapersonal coping skills, (6) interpersonal coping strategies, and (7) systemic supports. Conclusions: These results reinforces the need for integration of pediatric palliative care teaching and communication skills training into all undergraduate health care programs. Provider organizational support to meet the specific needs of the nurses in the community can help retain them in their role. It will also be important to develop standards for current and new palliative care services to ensure delivery of quality pediatric palliative care.

Personal Continuity of Care in a University-Based Primary Care Practice: Impact on Blood Pressure Control

Continuity of care is an important quality outcome of patient care. This study aimed to investigate the relationship between personal continuity and blood pressure (BP) control among the patients with hypertension in an academic primary care centre. Between January and May 2012, we conducted a retrospective review of medical records of patients with hypertension who had been followed up for at least 1 year in the Primary Care Clinic, University of Malaya Medical Centre, Malaysia. In this setting, doctors who provided care for hypertension included postgraduate family medicine trainees, non-trainee doctors and academic staff. Systematic random sampling (1:4) was used for patient selection. BP control was defined as less than 130/80 mm Hg for patients with diabetes mellitus, proteinuria and chronic kidney disease and less than 140/90 mm Hg for all other patients. Continuity of care was assessed using the usual provider continuity index (UPCI), which is the ratio of patient visits to the usual provider to the total number of visits to all providers in 1 year. A UPC index of zero denotes no continuity while an index of one reflects perfect continuity with only the usual provider. We reviewed a total of 1060 medical records. The patients’ mean age was 62.0 years (SD 10.4). The majority was women (59.2%) and married (85.7%). The mean number of visits in a year was 3.85 (SD 1.36). A total of 72 doctors had provided consultations (55 postgraduate family medicine trainees, 8 non-trainee doctors and 9 academic staff). The mean UPCI was 0.43 (SD 0.34). Target BP was achieved in 42% of the patients. There was no significant relationship between BP control and personal continuity after adjustment for total number of visits. Continuity of care was not associated with BP control in our centre. Further studies are needed to explore the reasons for this.

Decision making process and factors contributing to research participation among general practitioners: A grounded theory study

Introduction The participation of general practitioners (GPs) in primary care research is variable and often poor. We aimed to develop a substantive and empirical theoretical framework to explain GPs’ decision-making process to participate in research. Methods We used the grounded theory approach to construct a substantive theory to explain the decision-making process of GPs to participate in research activities. Five in-depth interviews and four focus group discussions were conducted among 21 GPs. Purposeful sampling followed by theoretical sampling were used to attempt saturation of the core category. Data were collected using semi-structured open-ended questions. Interviews were recorded, transcribed verbatim and checked prior to analysis. Open line-by-line coding followed by focus coding were used to arrive at a substantive theory. Memoing was used to help bring concepts to higher abstract levels. Results The GPs’ decision to participate in research was attributed to their inner drive and appreciation for primary care research and their confidence in managing their social and research environments. The drive and appreciation for research motivated the GPs to undergo research training to enhance their research knowledge, skills and confidence. However, the critical step in the GPs’ decision to participate in research was their ability to align their research agenda with priorities in their social environment, which included personal life goals, clinical practice and organisational culture. Perceived support for research, such as funding and technical expertise, facilitated the GPs’ participation in research. In addition, prior experiences participating in research also influenced the GPs’ confidence in taking part in future research. Conclusions The key to GPs deciding to participate in research is whether the research agenda aligns with the priorities in their social environment. Therefore, research training is important, but should be included in further measures and should comply with GPs’ social environments and research support.

Knowledge, Motivation Behavior and Level of Physical Activity for Medical Students

Introduction: Intense therapeutic ultrasound (ITU) is a newly established ultrasound-based, non-invasive therapy in which sound waves are concentrated and focused on musculoskeletal tissue for the purpose of pain reduction. This technology produces selective thermal coagulative changes over a small controlled area while leaving the surrounding tissue unaffected and without impacting the integrity of the dermis.Methods: A clinical study evaluating 29 patients (Age: 39 – 60, Male: 59%, Female 41%) for the effectiveness, safety and patient tolerance of Intense Therapeutic Ultrasound (ITU) for treatment of chronic (average length of symptoms prior to treatment: 12.9 Months), subcutaneous lateral Epicondylitis musculoskeletal tissue pain reduction was conducted. All patients enrolled in this IRB approved study had been previously diagnosed with Chronic Lateral Epicondylitis and had failed previous Standard-of-Care treatment regimen. Two ITU treatments were administered four weeks apart. Self-reported lateral elbow Universal Visual Analog pain scores and Patient-Rated Tennis Elbow Evaluation pain scores while performing normal daily tasks, were recorded pre-treatment (baseline measurement) and again at each follow-up time point - 4, 8, 12, and 26 weeks - after initial treatment. The goal for all subjects was to reduce overall pain and pain while performing everyday tasks by at least 25% on the average and more than 25% individually. While arbitrary, such criteria appear to be rigorous to reduce standard error and individual selfassessment variability.Results: Successful reduction of overall pain scores at 12 and 26 weeks following the first treatment are 88% and 82% of patients meeting the pain reduction criteria respectively. Also, at the same follow-up time points, patients reported an average VAS Pain Score reduction of 59% (Week 12) and 57% (Week 26) from a pre-treatment average of 5.08 down to an average of 2.2 at week 26. Additionally, patients reported an average pain reduction while performing everyday tasks of 58% and 61% respectively. Patient satisfaction remained over 80% for all follow-up dates.Conclusion: ITU is a promising non-invasive pain relief treatment for cases of chronic lateral epicondylitis.

Evaluating the Effectiveness of a Pragmatic Intervention in Reducing Blood Pressure in Patients with Hypertension

Background: Implementation of guidelines in hypertension remains challenging in primary care. Interventions are needed to improve hypertension management using guidelines. Objectives: To evaluate effectiveness of an intervention using guidelines in reducing blood pressure in patients with hypertension. Method: This before-and-after study was conducted in a primary care clinic for six months. The intervention involved professional training, availability of hypertension guideline and structured format of medical notes for hypertension. Primary outcome is the change in proportion of patients with uncontrolled BP (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg) and secondary outcome is the mean BP change at 6 months. Results: A total of 555 patients were recruited. At baseline, 227/555 (40.9%) had uncontrolled BP. By 6 months 186/463 (40.2%) was uncontrolled. Among those with uncontrolled BP at baseline, 51.8% had BP controlled at 6 months; SBP in the uncontrolled group decreased from 147.8 (11.2) to 138.8 (15.2) mmHg (p < 0.001, CI: 6.6, 11.4); DBP decreased from 83.7 (8.0) to 79.6 (8.3) mmHg (p < 0.001, CI: 2.610, 5.493). Among those with controlled BP, 34.4% became uncontrolled at 6 months. For the controlled group, the SBP in the controlled group increased from 125.8 (7.4) to 133.6 (12.8) mmHg (p < 0.001, CI: −9.475, −6.155); DBP increased from 75.6 (6.1) to 77.5 (7.4) mmHg (p < 0.001, CI: −2.984, −0.897). Conclusion: Although there was no change in the proportion of patients with uncontrolled BP, there was a significant reduction in mean BP of 9/4 mmHg in those with uncontrolled BP. Patients with controlled BP still need continuous monitoring.

Developing a clinical practice guideline implementation strategy based on needs, evidence and theory

Background Clinical practice guidelines (CPGs) are used to standardize care according to evidence-based recommendations. However, the implementation of CPGs in the real world varies; a possible reason for this is the lack of a systematic approach to the implementation of CPG. We, therefore, aimed to develop an intervention to improve the implementation of a local hypertension CPG based on the needs of healthcare professionals (HCPs), best available evidence, and theories.