Annemieke P. Bikker

Outcome related to impact on daily living: preliminary validation of the ORIDL instrument

BackgroundThe challenge of finding practical, patient-rated outcome measures is a key issue in the evaluation of health care systems and interventions. The ORIDL (Outcome in Relation to Impact on Daily Living) instrument (formerly referred to as the Glasgow Homoeopathic Hospital Outcomes Scale or GHHOS) has been developed to measure patients views of the outcome of their care by asking about change, and relating this to impact on daily life. The aim of the present paper is to describe the background and potential uses of the ORIDL, and to report on its preliminary validation in a series of three studies in secondary and primary care.MethodsIn the first study, 105 patients attending the Glasgow Homoeopathic Hospital (GHH) were followed-up at 12 months and changes in health status were measured by the EuroQol (EQOL) and the ORIDL. In the second study, 187 new patients at the GHH were followed-up at 3, 12, and 33 months, using the ORIDL, the Short Form 12 (SF-12), and the Measure Yourself Medical Outcome Profile (MYMOP). In study three, 323 patients in primary care were followed for 1 month post-consultation using the ORIDL and MYMOP. In all 3 studies the Patient Enablement Instrument (PEI) was also used as an outcome measure.ResultsStudy 1 showed substantial improvements in main complaint and well-being over 12 months using the ORIDL, with two-thirds of patients reporting improvements in daily living. These improvements were not significantly correlated with changes in serial measures of the EQOL between baseline and 12 months, but were correlated with the EQOL transitions measure. Study 2 showed step-wise improvements in ORIDL scores between 3 and 33 months, which were only weakly associated with similar changes in SF-12 scores. However, MYMOP change scores correlated well with ORIDL scores at all time points. Study 3 showed similar high correlations between ORIDL scores and MYMOP scores. In all 3 studies, ORIDL scores were also significantly correlated with PEI-outcome scores.ConclusionThere is significant agreement between patient outcomes assessed by the ORIDL and the EQOL transition scale, the MYMOP, and the PEI-outcome instrument, suggesting that the ORIDL may be a valid and sensitive tool for measuring change in relation to impact on life.

Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation

BACKGROUND Most patients with depression are managed in general practice. In deprived areas, depression is more common and poorer outcomes have been reported. AIM To compare general practice consultations and early outcomes for patients with depression living in areas of high or low socioeconomic deprivation. DESIGN AND SETTING Secondary data analysis of a prospective observational study involving 25 GPs and 356 consultations in deprived areas, and 20 GPs and 303 consultations in more affluent areas, with follow-up at 1 month. METHOD Validated measures were used to (a) objectively assess the patient centredness of consultations, and (b) record patient perceptions of GP empathy. RESULTS PHQ-9 scores >10 (suggestive of caseness for moderate to severe depression) were significantly more common in deprived than in affluent areas (30.1% versus 18.5%, P<0.001). Patients with depression in deprived areas had more multimorbidity (65.4% versus 48.2%, P<0.05). Perceived GP empathy and observer-rated patient-centred communication were significantly lower in consultations in deprived areas. Outcomes at 1 month were significantly worse (persistent caseness 71.4% deprived, 43.2% affluent, P = 0.01). After multilevel multiregression modelling, observer-rated patient centredness in the consultation was predictive of improvement in PHQ-9 score in both affluent and deprived areas. CONCLUSION In deprived areas, patients with depression are more common and early outcomes are poorer compared with affluent areas. Patient-centred consulting appears to improve early outcome but may be difficult to achieve in deprived areas because of the inverse care law and the burden of multimorbidity.

Length of consultations

Editor—Jenkins et al found that patients vary both in what they want from a consultation with their general practitioner and in what they get. They found a poor correlation between these and the length of the consultation. The catchy front cover headline “Consultations don’t have to be longer to be better” seriously overgeneralises these results. Some short consultations may be highly effective, but a systematic review earlier this year summarised a range of patient outcomes that are improved when doctors have more time. In one large English survey 12% of patients complained about having insufficient time with their general practitioner, but this figure rose to 30% when patients were seen for five minutes or less. It may be that the doctors need additional time in consultations—perhaps more than their patients. Medical practice has become more complex, and more needs to be done during the course of consultations. This may explain why clinical care is inferior in practices with short consultations. Patients may sometimes get what they want in short consultations—but they may not always realise that it isn’t good medical care. It is 16 years since David Morrell and I and colleagues published the first experimental study showing the limitations of short consultations. It is well past time to consign surgeries booked at intervals as short as five minutes to history. The current payment system for general practitioners encourages a “pack ’em in and sell ’em cheap” approach to general practice. This needs to be addressed in the contract currently being negotiated so that all general practitioners have time to offer their patients first class care.

Innovations and developments

We have two items this time. First we hear about something that could arguably be described as heroic. In these straitened times, the Leeds Unit of Primary Care has been running an innovative BSc in primary care. Not a luxury or a folly, surely, but heroic. Our second item comes from Glasgow and is about the CARE Approach for learning about consultations and compassionate care. The Approach is described in some detail and there is a link to the manual. There is much that is novel about this method.