Clarissa Hsu

Unanticipated Benefits of CAM Therapies for Back Pain: An Exploration of Patient Experiences

OBJECTIVES The goal of this research was to provide insight into the full range of meaningful outcomes experienced by patients who participate in clinical trials of complementary and alternative medicine (CAM) therapies. DESIGN Data for this study were assembled from five randomized trials evaluating six different CAM treatments for back pain. A conventional qualitative content analysis was conducted on responses to open-ended questions asked at the end of telephone interviews assessing treatment outcomes. SUBJECTS A total of 884 study participants who received CAM therapies completed post-treatment interviews. Of these, 327 provided qualitative data used in the analyses. RESULTS Our analysis identified a range of positive outcomes that participants in CAM trials considered important but were not captured by standard quantitative outcome measures. Positive outcome themes included increased options and hope, increased ability to relax, positive changes in emotional states, increased body awareness, changes in thinking that increased the ability to cope with back pain, increased sense of well-being, improvement in physical conditions unrelated to back pain, increased energy, increased patient activation, and dramatic improvements in health or well-being. The first five of these themes were mentioned for all of the CAM treatments, while others tended to be more treatment specific. A small fraction of these effects were considered life transforming. CONCLUSIONS Our findings suggest that standard measures used to assess the outcomes of CAM treatments fail to capture the full range of outcomes that are important to patients. In order to capture the full impact of CAM therapies, future trials should include a broader range of outcomes measures.

Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change

PURPOSE We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Motivations for Physician-assisted Suicide

AbstractOBJECTIVE: To obtain detailed narrative accounts of patients’ motivations for pursuing physician-assisted suicide (PAS). DESIGN: Longitudinal case studies. PARTICIPANTS: Sixty individuals discussed 35 cases. Participants were recruited through advocacy organizations that counsel individuals interested in PAS, as well as hospices and grief counselors. SETTING: Participants’ homes. MEASUREMENTS AND RESULTS: We conducted a content analysis of 159 semistructured interviews with patients and their family members, and family members of deceased patients, to characterize the issues associated with pursuit of PAS. Most patients deliberated about PAS over considerable lengths of time with repeated assessments of the benefits and burdens of their current experience. Most patients were motivated to engage in PAS due to illness-related experiences (e.g., fatigue, functional losses), a loss of their sense of self, and fears about the future. None of the patients were acutely depressed when planning PAS. CONCLUSIONS: Patients in this study engaged in PAS after a deliberative and thoughtful process. These motivating issues point to the importance of a broad approach in responding to a patient’s request for PAS. The factors that motivate PAS can serve as an outline of issues to explore with patients about the far-reaching effects of illness, including the quality of the dying experience. The factors also identify challenges for quality palliative care: assessing patients holistically, conducting repeated assessments of patients’ concerns over time, and tailoring care accordingly.

Healing in Primary Care: A Vision Shared by Patients, Physicians, Nurses, and Clinical Staff

PURPOSE We wanted to understand the views of patients and clinicians on the central concept of healing and to identify major facilitators of and barriers to promoting healing in primary care. METHODS We undertook a qualitative analysis of focus group discussions. Participants were drawn from primary care clinics of a large, integrated, health care system in Washington State in 2005. Nine focus groups included 84 participants: 28 patients, 23 primary care physicians (19 family physicians), 20 registered nurses, 11 licensed practical nurses, and 2 medical assistants. Randomly sampled established patients were aged from 21 to 65 years; 71% were female. RESULTS We found remarkable concordance across focus groups and among types of participants in the definition of healing: Healing is a dynamic process of recovering from a trauma or illness by working toward realistic goals, restoring function, and regaining a personal sense of balance and peace. Healing is a multidimensional process with physical, emotional, and spiritual dimensions. The key themes are as follows: (1) healing is multidimensional and holistic; (2) healing is a process, a journey; (3) the goal of healing is recovery or restoration; (4) healing requires the person to reach a place of personal balance and acceptance; and (5) relationships are essential to healing. Factors that facilitate healing help build relationships, improve communication, and share responsibility between the patient and clinician. Major barriers are logistical factors that limit high-quality time with healing professionals. CONCLUSIONS Patients and health care team members share a vision of healing and agree on ways to enhance the process in primary care.

Providing Care for Cancer Survivors in Integrated Health Care Delivery Systems: Practices, Challenges, and Research Opportunities

PURPOSE Optimal approaches to cancer survivorship care are needed. This study sought to identify practices, barriers, and research opportunities in meeting the care needs of cancer survivors in integrated health care delivery systems. METHODS This study was conducted at 10 sites within the Cancer Research Network, a National Cancer Institute-funded consortium of integrated health care delivery systems providing care for nearly 11 million enrollees. We identified 48 clinical leaders, administrators, and providers in oncology, primary care, nursing administration, and specialty care. Forty (83%) completed semi-structured, audio-recorded, transcribed telephone interviews, which we analyzed using an immersion-crystallization approach. RESULTS Respondents were aware of the needs of cancer survivors and the difficulties they face in transitioning from treatment to follow-up care. Respondents from all sites reported that oncology and primary care are jointly responsible for the care of cancer survivors, often through the use of electronic medical records. Many respondents were not familiar with standardized survivorship care plans. Only two sites had formal cancer survivorship programs in place, and two were developing such programs. Respondents at sites with and without programs acknowledged existing gaps in evidence on the effectiveness of formal survivorship care and expressed a desire for additional research. CONCLUSION Our exploratory study suggests an awareness of cancer survivorship care in integrated health care delivery systems, although approaches to providing such care vary across systems. These settings may offer a unique opportunity to develop, test, and implement innovative models of care, which can be systematically evaluated to inform and enhance cancer survivorship care in diverse health care settings.

Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions

PURPOSE The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. METHODS We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. RESULTS After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions. CONCLUSIONS The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

Incorporating patient decision aids into standard clinical practice in an integrated delivery system

Background. Randomized controlled trials show that patient decision aids (DAs) can promote shared decision making and improve decision quality. Despite this evidence, integration of DAs into routine clinical practice has proceeded slowly. Objective. To identify factors that promote or impede integrating DAs into clinical practice in a large health care delivery system. Design. Mixed-methods case study. Setting and Patients. Group Health, an integrated health plan and care delivery system in Washington state. Intervention. The project was carried out in 6 specialty service lines using 12 video-based DAs for preference-sensitive conditions related to elective surgical procedures. Measurements. Process data, site visits, meeting observations, and in-depth interviews conducted with clinical staff, project staff, and health plan leaders in 2009 and 2010. Results. The project established systemwide and clinic-specific processes that facilitated the distribution of approximately 10,000 DAs over 2 years. Several factors were identified as important for success in this implementation, including strong support from senior leaders, establishing a system for previsit ordering and providing timely feedback to teams about distribution rates, engaging providers and staff in development of the implementation process, and finding ways to address concerns about conditions that were perceived as life-threatening and/or time sensitive. Limitations. Limitations included lack of data on patient perspectives, an implementation setting with salaried providers, and frontline provider interviews conducted in only selected service lines. Conclusions. With strong leadership, financial support, and a well-defined implementation strategy, 12 video-based DAs in 6 specialty service lines were integrated into routine practice over 2 years. Findings from this demonstration may advance the ability of other organizations to use DAs effectively and promote widespread adoption of shared decision making in routine patient care.

The pursuit of physician-assisted suicide: role of psychiatric factors.

Physician-assisted suicide (PAS) has attracted considerable professional attention in recent years in the end-of-life care debate. The role of depression and other psychiatric illnesses on the patients pursuit of PAS is unclear. As part of a qualitative study exploring the motivations, deliberations, and complications experienced by persons with incurable diseases who were actively seeking PAS, we conducted semistructured interviews that were reviewed for psychiatric content. In total, 159 interviews were conducted with 60 participants concerning 12 prospective cases (12 patients and 20 family members) and 23 retrospective cases (28 family members), with more than 3600 pages of transcripts. Depressive symptoms, when present, were not described by the subjects and/or their family members to be an influential factor in their pursuit of PAS; no subject appeared or was described to suffer from depression-related decisional incapacity. Findings from this study, albeit from a small and self-selected sample, highlight not only the importance of avoiding a reductionistic understanding of the role of psychiatric illnesses in contributing to serious pursuit of PAS, but also the pressing need for scientifically rigorous studies of PAS in samples representative of the larger population.

Impact on Seniors of the Patient-Centered Medical Home: Evidence From a Pilot Study

PURPOSE To assess the impact on health care cost and quality among seniors of a patient-centered medical home (PCMH) pilot at Group Health Cooperative, an integrated health care system in Washington State. DESIGN AND METHODS A prospective before-and-after evaluation of the experience of seniors receiving primary care services at 1 pilot clinic compared with seniors enrolled at the remaining 19 primary care clinics owned and operated by Group Health. Analyses of secondary data on quality and cost were conducted for 1,947 seniors in the PCMH clinic and 39,396 seniors in the 19 control clinics. Patient experience with care was based on survey data collected from 487 seniors in the PCMH clinic and of 668 in 2 specific control clinics that were selected for their similarities in organization and patient composition to the pilot clinic. RESULTS After adjusting for baseline, seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales. Seniors in the PCMH clinic had significantly greater quality outcomes over time, but this difference was not significant relative to control. PCMH patients used more e-mail, phone, and specialist visits but fewer emergency services and inpatient admissions for ambulatory care sensitive conditions. At 1 and 2 years, the PCMH and control clinics did not differ significantly in overall costs. IMPLICATIONS A PCMH redesign can be associated with improvements in patient experience and quality without increasing overall cost.

A qualitative study of changes in expectations over time among patients with chronic low back pain seeking four CAM therapies

BackgroundThe relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants’ expectations of treatment changed over the course of a therapy.MethodsWe conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time.ResultsPre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a “positive outcome”. Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health.ConclusionsThe shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.