S. van Dulmen

Active Patient Participation in the Development of an Online Intervention

Background An important and challenging part of living with cancer relates to the repeated visits to the hospital. Since how patients cope between these post-diagnostic visits depends partly on the information and support received from their physician during the visits, it is important to make the most of them. Recent findings reinforce the importance of training not only the health care professionals in communication skills, but providing patients with support in communication as well. Delivering such supportive interventions online can have potential benefits in terms of accessibility, cost-effectiveness, and ability to tailor information to personal needs. However, problems with attrition (dropout, non-usage) during the test phase and poor uptake after implementation are frequently reported. The marginal level of engagement of the patient as end user seems to play a role in this. Therefore, recent research suggests integrating theory-based development methods with methods that promote involvement of the patient at an early stage. This paper describes a participatory protocol, used to let patients guide a theory-informed development process. Objective The objective of this project was to apply a bottom-up inspired procedure to develop a patient-centered intervention with corresponding evaluation and implementation plan. Methods The applied development protocol was based on the intervention mapping framework, combined with patient participatory methods that were inspired by the participation ladder and user-centred design methods. Results The applied protocol led to a self-directed online communication intervention aimed at helping patients gain control during their communications with health care professionals. It also led to an evaluation plan and an implementation plan. The protocol enabled the continuous involvement of patient research partners and the partial involvement of patient service users, which led to valuable insights and improvements. Conclusions The applied protocol realized patient participation on different levels throughout the entire project. Early involvement, involvement on different levels, and flexibility in terms of planning and setup seem to be preconditions to creating a bottom-up inspired development procedure with (seriously ill) patients. Further research is necessary to find out if a more patient-centered approach improves the implementation and uptake of eHealth interventions. Trial Registration Netherlands National Trial Register ID number: NTR3779; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3779 (Archived by WebCite at http://www.webcitation.org/6TdfALKxV).

Effectiveness of Peer Assessment for Implementing a Dutch Physical Therapy Low Back Pain Guideline: Cluster Randomized Controlled Trial

Background Clinical practice guidelines are considered important instruments to improve quality of care. However, success is dependent on adherence, which may be improved using peer assessment, a strategy in which professionals assess performance of their peers in a simulated setting. Objective The aim of this study was to determine whether peer assessment is more effective than case-based discussions to improve knowledge and guideline-consistent clinical reasoning in the Dutch physical therapy guideline for low back pain (LBP). Design A cluster randomized controlled trial was conducted. Setting and Participants Ten communities of practice (CoPs) of physical therapists were cluster randomized (N=90): 6 CoPs in the peer-assessment group (n=49) and 4 CoPs in the case-based discussion group (control group) (n=41). Intervention Both groups participated in 4 educational sessions and used clinical patient cases. The peer-assessment group reflected on performed LBP management in different roles. The control group used structured discussions. Measurements Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0–100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20–100). Results Vignettes were completed by 78 participants (87%). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4% in the peer-assessment group, whereas the control group showed a decline of 0.1% (estimated group difference=8.7%, 95% confidence interval=3.9 to 13.4). No group differences were found on self-reflection. Limitations The small sample size, a short-term follow-up, and the use of vignettes as a proxy for behavior were limitations of the study. Conclusions Peer assessment leads to an increase in knowledge and guideline-consistent clinical reasoning.

The European Association for Communication in Healthcare.

In September 2000 a special meeting was called during the International Conference on Health And Communication in Barcelona to launch a new European association. The name of the association is EACH, the European Association for Communication in Healthcare. In January 2001, the frist formal board meeting took place in The Netherlands. During this meeting, thirteen researchers, medical educators and practitioners from eight European countries met in Utrecht to discuss the objectives and the provisional agenda for the first two years. (aut. ref.)

The impact of watching educational video clips on analogue patients' physiological arousal and information recall

OBJECTIVEnInvestigating the influence of watching three educational patient-provider interactions on analogue patients emotional arousal and information recall.nnnMETHODSnIn 75 analogue patients the emotional arousal was measured with physiological responses (electrodermal activity and heart rate) and self-reported arousal.nnnRESULTSnA moderate increased level of physiological arousal was measured but not too much to inflict emotional distress. Recall of information was within the pursued range.nnnCONCLUSIONnHence, physiological arousal is not expected to hinder the goals we pursue with our online intervention.nnnPRACTICE IMPLICATIONSnStill, developers and researchers should remain attentive to the self-reported (conscious) and hidden (subconscious) emotions evoked by the content of educational video clips presented in self-help interventions. A moderate increased level of arousal is preferred to increase the learning capacity. However, too much arousal may decrease the learning capacity and may cause distress, which should obviously be avoided for ethical reasons.

An Online Tailored Self-Management Program for Patients With Rheumatoid Arthritis: A Developmental Study

Background Every day rheumatoid arthritis (RA) patients make many decisions about managing their disease. An online, computer-tailored, self-management program can support this decision making, but development of such a program requires the active participation of patients. Objective To develop an online, computer-tailored, self-management program integrated with the nursing care, as nurses have an important role in supporting self-management behavior. Methods The intervention mapping framework was used to develop the program. Development was a multistep process: (1) needs assessment; (2) developing program and change objectives in a matrix; (3) selecting theory-based intervention methods and practical application strategies; (4) producing program components; (5) planning and adoption, implementation, and sustainability; and (6) planning for evaluation. Results After conducting the needs assessment (step 1), nine health-related problems were identified: (1) balancing rest and activity, (2) setting boundaries, (3) asking for help and support, (4) use of medicines, (5) communicating with health professionals, (6) use of assistive devices, (7) performing physical exercises, (8) coping with worries, and (9) coping with RA. After defining performance and change objectives (step 2), we identified a number of methods which could be used to achieve them (step 3), such as provision of general information about health-related behavior, self-monitoring of behavior, persuasive communication, modeling, and self-persuasion and tailoring. We described and operationalized these methods in texts, videos, exercises, and a medication intake schedule. The resulting program (step 4) consisted of an introduction module and nine modules dealing with health-related problems. The content of these modules is tailored to the user’s self-efficacy, and patients can use the online program as often as they want, working through a module or modules at their own speed. After implementation (step 5), the program will be evaluated in a two-center pilot trial involving 200 RA patients. Log-in data and qualitative interviews will used for a process evaluation. Conclusions The intervention mapping framework was used to guide development of an online computer-tailored self-management program via a process which could serve as a model for the development of other interventions. A pilot randomized controlled trial (RCT) will provide insight into the important outcome measures in preparation for a larger RCT. The process evaluation will provide insight into how RA patients use the program and the attrition rate. Trial Registration Netherlands Trial Register (NTR): NTR4871; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4871 [accessed 13-NOV-15] http://www.webcitation.org/6d1ZyIoEy

Development and Evaluation of an Implementation Strategy for Collecting Data in a National Registry and the Use of Patient-Reported Outcome Measures in Physical Therapist Practices: Quality Improvement Study

Background. In 2013, the Royal Dutch Society for Physical Therapy launched the program “Quality in Motion.” This program aims to collect data from electronic health record systems in a registry that is fed back to physical therapists, facilitating quality improvement. Purpose. The purpose of this study was to describe the development of an implementation strategy for the program and to evaluate the feasibility of building a registry and implementing patient‐reported outcome measures (PROMs) in physical therapist practices. Methods. A stepwise approach using mixed methods was established in 3 consecutive pilots with 355 physical therapists from 66 practices. Interim results were evaluated using quantitative data from a self‐assessment questionnaire and the registry and qualitative data from 21 semistructured interviews with physical therapists. Descriptive statistics and McNemars symmetry chi‐squared test were used to summarize the feasibility of implementing PROMs. Results. PROMs were selected for the 5 most prevalent musculoskeletal conditions in Dutch physical therapist practices. A core component of the implementation strategy was the introduction of knowledge brokers to support physical therapists in establishing the routine use of PROMs in clinical practice and to assist in executing peer assessment workshops. In February 2013, 30.3% of the physical therapist practices delivered 4.4 completed treatment episodes per physical therapist to the registry; this increased to 92.4% in November 2014, delivering 54.1 completed patient episodes per physical therapist. Pre‐ and posttreatment PROM use increased from 12.2% to 39.5%. Limitations. It is unclear if the participating physical therapists reflect a representative sample of Dutch therapists. Conclusion. Building a registry and implementing PROMs in physical therapist practices are feasible. The routine use of PROMs needs to increase to ensure valid feedback of outcomes. Using knowledge brokers is promising for implementing the program via peer assessment workshops.

Psychometric properties of the PROMIS Physical Function item bank in patients receiving physical therapy.

Objectives The Patient-Reported Outcomes Measurement Information System (PROMIS) is a universally applicable set of instruments, including item banks, short forms and computer adaptive tests (CATs), measuring patient-reported health across different patient populations. PROMIS CATs are highly efficient and the use in practice is considered feasible with little administration time, offering standardized and routine patient monitoring. Before an item bank can be used as CAT, the psychometric properties of the item bank have to be examined. Therefore, the objective was to assess the psychometric properties of the Dutch-Flemish PROMIS Physical Function item bank (DF-PROMIS-PF) in Dutch patients receiving physical therapy. Design Cross-sectional study. Setting and participants 805 patients >18 years, who received any kind of physical therapy in primary care in the past year, completed the full DF-PROMIS-PF (121 items). Methods Unidimensionality was examined by Confirmatory Factor Analysis and local dependence and monotonicity were evaluated. A Graded Response Model was fitted. Construct validity was examined with correlations between DF-PROMIS-PF T-scores and scores on two legacy instruments (SF-36 Health Survey Physical Functioning scale [SF36-PF10] and the Health Assessment Questionnaire Disability-Index [HAQ-DI]). Reliability (standard errors of theta) was assessed. Results The results for unidimensionality were mixed (scaled CFI = 0.924, TLI = 0.923, RMSEA = 0.045, 1th factor explained 61.5% of variance). Some local dependence was found (8.2% of item pairs). The item bank showed a broad coverage of the physical function construct (threshold-parameters range: -4.28–2.33) and good construct validity (correlation with SF36-PF10 = 0.84 and HAQ-DI = -0.85). Furthermore, the DF-PROMIS-PF showed greater reliability over a broader score-range than the SF36-PF10 and HAQ-DI. Conclusions The psychometric properties of the DF-PROMIS-PF item bank are sufficient. The DF-PROMIS-PF can now be used as short forms or CAT to measure the level of physical function of physiotherapy patients.

The effect of electronic monitoring feedback on medication adherence and clinical outcomes: A systematic review

Objective This study aims to assess the efficacy of Electronic Monitoring Feedback (EMF) as an intervention to improve medication adherence (i.e. dose- or full adherence) and clinical outcomes in adult patients. Methods A systematic search was performed in Medline, EMBASE, PsycINFO and Web of Science and reported according to the PRISMA guidelines. Randomised controlled trials (RCTs) comparing EMF with usual care were identified to systematically summarise the evidence for use of EMF in improving medication adherence and clinical outcomes. The GRADE approach was used to assess the quality of the body of evidence. Results Of 9,993 initially-identified studies, ten studies (four of high-quality and six of low-quality) were included. The sample size of the studies included varied from 18 to 205 patients. Four of the six studies (66.7%) reported a significant positive effect of EMF on mean dose adherence levels, whereas a significant positive effect of EMF on mean full adherence levels was found in all of the included studies (100%, five out of five of the studies included). A significant positive effect of EMF on clinical outcomes was reported in one of the seven studies included. The overall effect of EMF on mean dose- and full adherence was positive and the overall effect of EMF on clinical outcomes was inconclusive. Conclusion Considering the positive effect of EMF on medication adherence, EMF might be a promising intervention to enhance medication adherence. However, the effect of EMF on clinical outcomes was inconclusive. Prior to implementing EMF in clinical practice, future research with high-quality studies (e.g. adequate sample sizes, follow-up periods and no interfering co-interventions) is required to examine the (long-term) efficacy of EMF.

AB1092-HPR Developing An Online Self-Management Program for Rheumatoid Arthritis Patients, Using Behavioral Change Techniques and Patients' Input

Background To support individual behavioral change by self-management interventions, behavioral change techniques (BCT) may be helpful to induce behavior change [1]. Conditions for effectivity of BCTs are that they fit to experienced problems in self-management and that the conditions under which they work (parameters) are taken into account. So important steps in the development of self-management programs are 1) identifying the self-management behavioral problems and factors (determinants) affecting these problems in patients, 2) link BCT techniques to these behavioral problems and determinants, 3) identifying parameters of the BCTs and 4) implement BCT techniques into the intervention [2]. Objectives Development of an online self-management program for Rheumatoid Arthritis (RA) patients. Methods A panel of 5 RA patients and 5 health professionals identified self-management behavioral problems and prioritized them. Determinants of these behavioral problems were identified in literature and confirmed by patients. Two independent researchers coded techniques from a list of BCTs linked to the determinants of the identified problems with the panel and discussed, which led to consensus [3]. Afterwards, parameters of BCTs where identified from literature. Lastly, RA patients input during a meeting was used to implement the techniques into the intervention. Results In total 9 behavioral problems related to self-management were mentioned, namely: balancing rest and activity, setting boundaries in daily life, asking for help and supportuse of medicines, communication with health professionals, use of assistive devices, performing physical exercises, coping with worries, and coping with RA. Determinants of these problems were: knowledge, awareness, risk perception, social influence, attitude, self-efficacy, and habits. To change patients self-management behavior, 15 BCTs were identified, for example persuasive communication, guided practice and self-monitoring. After identifying, the BCTs were linked to the determinants of behavioral problems and parameters where identified.An example of the BCT modeling, linked to a low self-efficacy an parameters, is presented in table 1. Conclusions Although the BCT taxonomy was helpful as a starting point to induce behavioral change in self-management, firstly the problems related to self-management and their determinants must be clear. Afterwards, the parameters of the BCTs and patients preferences need to be taken into account when translating these techniques into the self-management program. References Abraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health Psychol, 27(3), 379–387. doi: 10.1037/0278-6133.27.3.379. Kok, G., Schaalma, H., Ruiter, R. A. C., Van Empelen, P., & Brug, J. (2004). Intervention mapping: A protocol for applying health psychology theory to prevention programmes. Journal of Health Psychology, 9(1), 85–98. doi: 10.1177/1359105304038379. De Bruin, M., Kok. G., Schaalma, H., Hospers, H. (2007). Coding manual for behavioral change techniques http://www.biomedcentral.com/content/supplementary/1748-5908-7-92-S2.pdf. Disclosure of Interest None declared

THU0597 Effectiveness of a Group-Based Intervention to Improve Medication Beliefs and Adherence in Non-Adherent Patients with Rheumatoid Arthritis: A Randomized Controlled Trial

Background Medication adherence in patients with rheumatoid arthritis (RA) is suboptimal, with adherence rates between 30% to 80%. Existing interventions to improve medication adherence are mostly complex and have small effect sizes. We therefore developed a short, group-based intervention to change the balance in necessity and concern beliefs about medication, and to improve adherence to Disease Modifying Anti Rheumatic Drugs (DMARDs) in non-adherent RA patients. Objectives This randomized clinical trial assessed the effect of a group-based intervention on patients’ balance in beliefs about medication (primary outcome, measured with the BMQ: beliefs about medicine questionnaire), and medication adherence. Methods Adult, non-adherent (determined with the CQR: Compliance Questionnaire on Rheumatology) RA patients using DMARDs were randomized into the intervention arm, consisting of two motivational interviewing based group sessions led by a pharmacist, a homework assignment, and a follow-up call, or into the control arm, in which participants received brochures about their currently used DMARDs. Measurements were conducted at baseline, and at one week, six months and 12 months follow-up. Generalized Estimating Equations were used to estimate intervention effects. Results 123 patients, (mean age: 60 years, 69% female) were randomized. No differences in improvement in medication adherence, and in the change in the balance between necessity and concern beliefs about medication were detected between the two arms. Only at 12 months follow-up, participants in the control arm had stronger necessity beliefs about medication than participants in the intervention arm (b and 95% CI indicating this difference, corrected for baseline and with control group as reference category: -1.1 (-2.0 - -0.2)). Conclusions Our group-based intervention neither changed the beliefs about medication, nor improved medication adherence to DMARDs in non-adherent patients with rheumatoid arthritis. References Van den Bemt BJF, Zwikker HE, Van den Ende CHM (2012). Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature. Expert Rev. Clin. Immunol. 8(4), 337–351. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2008; CD000011. Zwikker H, Van den Bemt B, Van den Ende C, Van Lankveld W, Den Broeder A, Van den Hoogen F et al. (2012). Development and content of a group-based intervention to improve medication adherence in non-adherent patients with rheumatoid arthritis. Patient Education and Counseling, 89: 143–151. Disclosure of Interest None Declared