Anna Kiessling

Active interprofessional education in a patient based setting increases perceived collaborative and professional competence

Background: Interprofessional competence can be defined as knowledge and understanding of their own and the other team members’ professional roles, comprehension of communication and teamwork and collaboration in taking care of patients. Aim: To evaluate whether students perceived that they had achieved interprofessional competence after participating in clinical teamwork training. Method: Six hundred and sixteen students from four undergraduate educational programs–medicine, nursing, physiotherapy and occupational therapy–participated in an interprofessional course at a clinical education ward. The students filled out pre and post questionnaires (96% response rate). Results: All student groups increased their perceived interprofessional competence. Occupational therapy and medical students had the greatest achievements. All student groups perceived improved knowledge of the other three professions’ work (p = 0.000000) and assessed that the course had contributed to the understanding of the importance of communication and teamwork to patient care (effect size 1.0; p = 0.00002). The medical students had the greatest gain (p = 0.00093). All student groups perceived that the clarity of their own professional role had increased significantly (p = 0.00003). Occupational therapy students had the greatest gain (p = 0.000014). Conclusions: Active patient based learning by working together in a real ward context seemed to be an effective means to increase collaborative and professional competence.

Effects of interprofessional education on patient perceived quality of care

Background: Active patient-based learning by working together at an interprofessional clinical education ward (CEW) increases collaborative and professional competence among students. Aim: To assess the patients’ perceptions of collaborative and communicative aspects of care when treated by interprofessional student teams as compared to usual care. Method: Patients treated by student teams (medical, nurse, physiotherapy and occupational therapy students) at a CEW comprised the intervention group. Patients treated at a regular ward were taken as controls. The patients answered a questionnaire representing collaborative and communicative aspects of care. Questionnaires from CEW (n = 84) and control (n = 62) patients were obtained (82% vs 73% response rates). Results: CEW patients rated a significantly higher grade of own participation in decisions regarding treatment as compared to controls (p = 0.006). They did further rate a higher grade of satisfaction with information regarding need of help at home (p = 0.003) and perceived that the CEW staff had taken their home situation into account at a higher grade in the preparation of discharge (p = 0.0002). Finally, CEW patients felt better informed (p = 0.02). Conclusion: Patients perceived a higher grade of quality of care as compared to controls with no signs of disadvantages when treated and informed by supervised interprofessional student teams.

Long-term effects of an expanded cardiac rehabilitation programme after myocardial infarction or coronary artery bypass surgery: a five-year follow-up of a randomized controlled study

Objective: To investigate the long-term effect of expanded cardiac rehabilitation on a composite end-point, consisting of cardiovascular death, myocardial infarction or readmission for cardiovascular disease, in patients with coronary artery disease. Design: Single-centre prospective randomized controlled trial. Setting: University hospital. Subjects: Two hundred and twenty-four patients with acute myocardial infarction or undergoing coronary artery by-pass grafting. Intervention: Patients were randomized to expanded cardiac rehabilitation (a one-year stress management programme, increased physical training, staying at a ‘patient hotel’ for five days after the event, and cooking sessions), or to standard cardiac rehabilitation. Main measures: Data on cardiovascular death, myocardial infarction, readmission for cardiovascular disease and days at hospital for cardiovascular reasons were obtained from national registries of the Swedish National Board of Health and Welfare. Results: The primary end-point occurred in 121 patients altogether (54%). The number of cardiovascular events were reduced in the expanded rehabilitation group compared with the standard cardiac rehabilitation (53 patients (47.7%) versus 68 patients (60.2%); hazard ratio 0.69; P = 0.049). This was mainly because of a reduction of myocardial infarctions in the expanded rehabilitation group. During the five years 12 patients (10.8%) versus 23 patients (20.3%); hazard ratio 0.47; P = 0.047 had a myocardial infarction. Days at hospital for cardiovascular reasons were significantly reduced in patients who received expanded cardiac rehabilitation (median 6 days) compared with standard cardiac rehabilitation (median 10 days; P = 0.02). Conclusion: Expanded cardiac rehabilitation after acute myocardial infarction or coronary artery bypass grafting reduces cardiovascular morbidity and days at hospital for cardiovascular reasons.

Case-Based Training of Evidence-Based Clinical Practice in Primary Care and Decreased Mortality in Patients With Coronary Heart Disease

PURPOSE We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD). METHODS A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners (n = 54) and patients with CHD (n = 88) were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists (n = 167) served as an internal specialist comparison group. Altogether, 255 consecutive patients were included. Cox regression analysis was used to detect any survival benefit of the intervention. RESULTS At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group (P = .02), with a hazard ratio of 0.45 (95% confidence interval, 0.20–0.95). This difference was mainly due to reduced cardiovascular mortality in the intervention group (P = .01). In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist. CONCLUSIONS Use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.

Adherence to national guidelines for children with asthma at primary health centres in Sweden: potential for improvement

BACKGROUND Although asthma is the most common chronic paediatric disease in Western Europe, the extent of adherence to guidelines for primary care management of paediatric asthma remains unclear. AIMS To evaluate adherence to national guidelines for primary care management of children with asthma. METHODS This survey involved 18 primary healthcare centres in Stockholm, Sweden. The medical records of 647 children aged 6 months to 16 years with a diagnosis of asthma, obstructive bronchitis, or cough were selected and scrutinised. 223 children with obstructive bronchitis or cough not fulfilling the evidence-based criteria for asthma were excluded, yielding a total of 424 subjects. Documentation of the most important indicators of quality as stipulated in national guidelines (i.e., tobacco smoke, spirometry, pharmacological treatment, patient education, and demonstration of inhalation technique) was examined. RESULTS Only 22% (n=49) of the children 6 years of age or older had ever undergone a spirometry test, but the frequency was greater when patients had access to an asthma nurse (p=0.003). Although 58% (n=246) of the total study population were treated with inhaled steroids, documented patient education and demonstration of inhalation technique was present in 14% (n=59). Exposure to tobacco smoke was documented in 14% (n=58). CONCLUSIONS This study reveals a substantial gap between the actual care provided for paediatric asthma and the recommendations formulated in national guidelines.

Perceived cognitive function is a major determinant of health related quality of life in a non-selected population of patients with coronary artery disease--a principal components analysis.

AbstractObjective: To assess health related quality of life (HRQL) and explore its underlying structure in a non-selected population of patients with coronary artery disease (CAD). Design, setting and subjects: HRQL was estimated by the disease specific Cardiac Health Profile (CHP) questionnaire and the EuroQol-VAS (EQ) in 253 consecutive unselected CAD patients in Södertälje, Stockholm County, Sweden. Explorative factor analysis was used to identify independent dimensions of HRQL. Current angina was ranked according to Canadian Cardiovascular Society Classification (CCS). Results: Four independent principal factors representing perceived cognitive, physical, social and emotional functions underlying the patients’ HRQL were found. Identical factors were recognized with an alternate technique. The major factor – explaining 43% of HRQL – was perceived cognitive function reflecting ability to concentrate, activity drive, memory and problem solving. Cognitive function correlated to EQ but not to CCS. Perceived physical function/general health explained 9% of HRQL and was as expected related both to EQ and CCS. Total CHP scores differed significantly to those of healthy controls. Conclusions: Perceived cognitive function seems to be a major determinant of HRQL in CAD patients. This, in addition to earlier reports of possible prognostic information of reduced cognitive function, would prompt us to propose that HRQL assessments should include questions aimed to assess cognitive function.

Time trends of chest pain symptoms and health related quality of life in coronary artery disease

BackgroundThere is at present a lack of knowledge of time trends in health related quality of life (HRQL) in common patients with coronary artery disease (CAD) treated in ordinary care. The objective of this study is to assess and compare time trends of health related quality of life (HRQL) and chest pain in patients with coronary artery disease.Methods253 consecutive CAD patients in Stockholm County, Sweden – 197 males/56 females; 60 ± 8 years – were followed during two years. Perceived chest pain symptoms and three global assessments of HRQL were assessed at baseline, after one and after two years. EuroQol-5 dimension (EQ-5D) with a predefined focus on function and symptoms; the broader tapping global estimates of HRQL; EuroQol VAS (EQ-VAS) and Cardiac Health Profile (CHP) were used. Chest pain was ranked according to Canadian Cardiovascular Society (CCS). Change in HRQL was analysed by a repeated measurements ANOVA and chest pain symptoms were analysed by Friedman non-parametric ANOVA.ResultsPerceived chest pain decreased during the two years (p < 0.00022); CCS 0: 41–51%; CCS 1: 19–15%; CCS 2: 31–27%; CCS 3: 5–4% and CCS 4: 4–2%. By contrast, HRQL did not change: EQ-5D: 0.76 (CI 0.73–0.79) -0.78 (CI 0.75–0.81), EQ-VAS: 0.68 (CI 0.66–0.71)-0.68 (CI 0.65–0.71) and CHP: 0.66 (CI 0.64–0.69) -0.66 (CI 0.64–0.69).ConclusionHRQL did not increase despite a reduction in the severity of chest pain during two years. This implies that the major part of HRQL in these consecutive ordinary patients with CAD is unresponsive to change in chest pain symptoms.

Sickness certification as a complex professional and collaborative activity - a qualitative study

BackgroundPhysicians have an important but problematic task to issue sickness certifications. A manifold of studies have identified a wide spectrum of medical and insurance-related problems in sickness certification. Despite educational efforts aiming to improve physicians’ knowledge of social insurance medicine there are no signs of reduction of these problems. We hypothesised that the quality deficits is not only due to lack of knowledge among issuing physicians. The aim of the study was to explore physicians’ challenges when handling sickness certification in relation to their professional roles as physicians and to their interaction with different stakeholders.MethodsOne hundred seventy-seven physicians in Stockholm County, Sweden, participated in a sick-listing audit program. Participants identified challenges in handling sick-leave issues and formulated action plans for improvement. Challenges and responsible stakeholders were identified in the action plans. To deepen the understanding facilitators of the program were interviewed. A qualitative content analysis was performed exploring challenge categories and categories of stakeholders with responsibility to initiate actions to improve the quality of the sick-listing process. The challenge categories were then related by their content to professional competence roles in accord with the Canadian Medical Education Directions for Specialists (CanMEDS) framework and to the stakeholder categories.ResultsSeven categories of challenges were identified. Practitioner patient interaction, Work capacity assessment, Interaction with the Social Insurance Administration, The patient’s workplace and the labour market, Sick-listing practice, Collaboration and resource allocation within the Health Care System, Leadership and routines at the Health Care Unit. The challenges were related to all seven CanMEDS roles. Five categories of stakeholders were identified and several stakeholders were involved in each challenge category.ConclusionsPhysicians performing sickness certification tasks experience a complex variety of challenges. From physician perspective actions to handle these need to be initiated in interaction with both medical and non-medical stakeholders. The relation between the challenges and a well-established professional competence framework revealed a complex pattern. Thus, from a public health perspective, educational activities aimed to improve the sick-listing process should address all physician competences including identification and interaction with stakeholders, and not just knowledge of social insurance medicine.

Emotions delay care-seeking in patients with an acute myocardial infarction

Background: In acute myocardial infarction the risk of death and loss of myocardial tissue is at its highest during the first few hours. However, the process from symptom onset to the decision to seek medical care can take time. To comprehend patients’ pre-hospital delay, attention must be focused on the circumstances preceding the decision to seek medical care. Aim: To add a deeper understanding of patients’ thoughts, feelings and actions that preceded the decision to seek medical care when afflicted by an acute myocardial infarction. Methods: Fourteen men and women with a first or second acute myocardial infarction were interviewed individually in semi-structured interviews. Data were analysed by qualitative content analysis. Results: Four themes were conceptualized: ‘being incapacitated by fear, anguish and powerlessness’, ‘being ashamed of oneself’, ‘fear of losing a healthy identity’ and ‘striving to avoid fear by not interacting with others’. Patients were torn between feelings such as anguish, fear, shame and powerlessness. They made an effort to uphold their self-image as being a healthy person thus affected by an unrecognized discomfort. This combined with a struggle to protect others from involvement, strengthened the barriers to seeking care. Conclusions: The present study indicates that emotional reactions are important and influence patients’ pre-hospital behaviour. Being ashamed of oneself stood out as a novel finding. Emotions might be an important explanation of undesired and persisting patient delays. However, our findings have to and should be evaluated quantitatively. Such a study is in progress.

Participatory learning: a Swedish perspective

During recent years, numerous recommendations and practice guidelines on the subject of secondary prevention of coronary heart disease have been produced throughout Europe. Congresses, educational meetings, and lectures have been held with the purpose of facilitating the implementation of evidence based clinical practice. Furthermore, printed educational materials including reviews and clinical guidelines have been provided to all physicians concerned. Despite all this effort, the gap is still wide between what is achieved in clinical practice, and what could be achieved according to scientific evidence based goals for secondary prevention in patients with coronary heart disease.1 The reason for this is probably that there are several barriers and complexities between the guidelines and a behavioural change in real clinical practice.2,3 The means of changing this lies in the choice of educational method, rather than producing more scientific evidence. A recent comment from a European perspective on guidelines and global risk states that “The real task facing cardiovascular medicine is implementation of these recommendations into clinical practice”.4 Thus, the question is: How to perform this? Which physicians are the key target population? Cardiologists, internists, generalists and, or general practitioners? Perhaps the patients? Which implementation methods should be used? Are these methods evidence based? How should the results be evaluated? A recent Swedish study using the case method learning technique—that is, a participatory learning method—holds promise and shows significant results in secondary prevention of patients with coronary heart disease, even at the patient level in primary care.5 The reason why we focused on education for general practitioners, and not for specialists, is that the main cohort of patients with stable coronary heart disease, at least in Sweden, is taken care of by generalists. However, coronary heart disease patients represent only a minority of the patients treated at those …