Interventions before consultations for helping patients address their information needs

  • Review
  • Intervention

Authors


Abstract

Background

Patients often do not get the information they require from doctors and nurses. To address this problem, interventions directed at patients to help them gather information in their healthcare consultations have been proposed and tested.

Objectives

To assess the effects on patients, clinicians and the healthcare system of interventions which are delivered before consultations, and which have been designed to help patients (and/or their representatives) address their information needs within consultations.

Search methods

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library (issue 3 2006); MEDLINE (1966 to September 2006); EMBASE (1980 to September 2006); PsycINFO (1985 to September 2006); and other databases, with no language restriction. We also searched reference lists of articles and related reviews, and handsearched Patient Education and Counseling (1986 to September 2006).

Selection criteria

Randomised controlled trials of interventions before consultations designed to encourage question asking and information gathering by the patient.

Data collection and analysis

Two researchers assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of five outcomes.

Main results

We identified 33 randomised controlled trials, from 6 countries and in a range of settings. A total of 8244 patients was randomised and entered into studies. The most common interventions were question checklists and patient coaching. Most interventions were delivered immediately before the consultations.

Commonly-occurring outcomes were: question asking, patient participation, patient anxiety, knowledge, satisfaction and consultation length. A minority of studies showed positive effects for these outcomes. Meta-analyses, however, showed small and statistically significant increases for question asking (standardised mean difference (SMD) 0.27 (95% confidence interval (CI) 0.19 to 0.36)) and patient satisfaction (SMD 0.09 (95% CI 0.03 to 0.16)). There was a notable but not statistically significant decrease in patient anxiety before consultations (weighted mean difference (WMD) -1.56 (95% CI -7.10 to 3.97)). There were small and not statistically significant changes in patient anxiety after consultations (reduced) (SMD -0.08 (95%CI -0.22 to 0.06)), patient knowledge (reduced) (SMD -0.34 (95% CI -0.94 to 0.25)), and consultation length (increased) (SMD 0.10 (95% CI -0.05 to 0.25)). Further analyses showed that both coaching and written materials produced similar effects on question asking but that coaching produced a smaller increase in consultation length and a larger increase in patient satisfaction.

Interventions immediately before consultations led to a small and statistically significant increase in consultation length, whereas those implemented some time before the consultation had no effect. Both interventions immediately before the consultation and those some time before it led to small increases in patient satisfaction, but this was only statistically significant for those immediately before the consultation. There appear to be no clear benefits from clinician training in addition to patient interventions, although the evidence is limited.

Authors' conclusions

Interventions before consultations designed to help patients address their information needs within consultations produce limited benefits to patients. Further research could explore whether the quality of questions is increased, whether anxiety before consultations is reduced, the effects on other outcomes and the impact of training and the timing of interventions. More studies need to consider the timing of interventions and possibly the type of training provided to clinicians.

摘要

背景

在會診前介入協助滿足病人資訊上的需求

病人通常沒有從醫護人員那裡得到他們所需要的資訊,在計劃做醫療診察前,直接介入協助病人並幫忙收集所需要的資訊,可以解決這個問題。

目標

為評估病人、醫療人員、以及醫療體系關於在診察前協助病人及家屬滿足資訊上需求的介入方式及效果

搜尋策略

我們搜尋了Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library (2006年第3期) ,同時也搜尋了MEDLINE(1966年至2006年9月),EMBASE(1980年至2006年9月); PsycINFO(1985年至2006年9月)以及其他資料庫,我們並沒有對語言設限。我們還搜尋了參考文獻目錄的文章和相關評論,並以人工方式搜尋了Patient Education and Counseling(1986年至2006年9月)。

選擇標準

在診察前的介入措施,以鼓勵病人提問及收集相關資訊為主的隨機對照臨床試驗。

資料收集與分析

2位評論作者分別評估了搜尋之結果,以確認潛在相關的研究,選擇納入分析之研究並擷取其數據。我們綜合敘述了納入的臨床試驗,以及5項綜合分析的結果。

主要結論

我們共確認了6個診間環境不同的國家中所進行的33個隨機對照臨床試驗。總共有8244位病人被隨機分配到研究中,最主要的介入措施為問題清單以及引導病人。大多數的介入措施都在診察前一刻執行,通常評估的結果為:發問、病人的參與、病人的焦慮、知識、滿意度以及診察時間的長短。有一小部分的研究結果顯示,對這些結果有正面的評價。然而綜合分析的結果卻顯示統計學上有重要的意義,在會診時發問(標準化均數差SMD為0.27,95% 信賴區間CI介於0.19到0.36之間)以及病人滿意度(標準化均數差SMD為0.09,95% 信賴區間CI介於0.03到0.16之間)都有小幅的增加。有一個值得注意卻沒有統計上意義的結果,就是在會診前介入協助病人,有減輕焦慮的效果(加權後均數差WMD為 −1.56,95% 信賴區間CI介於 −7.10到3.97之間)。在會診結束後的一些改變,像是病人的焦慮獲得減輕(標準化均數差SMD為 −0.08,95% 信賴區間CI介於 −0.22到0.06之間),病人的知識減少(標準化均數差SMD為 −0.34,95% 信賴區間CI介於 −0.94到0.25之間),以及會診的時間延長(標準化均數差SMD為0.10,95% 信賴區間CI介於 −0.05到0.25之間),在統計學上都沒有顯著的意義。更進一步的分析顯示出,不管是從旁引導或書面工具,在診察時發問都產生了類似的效用,但是從旁引導在會診時間上有小幅度的增加,在病人滿意度上則是有較大幅度的增加。在會診前一刻介入協助輔導病人,會導致在會診時間有微小且統計上顯著性的增加;但若是在會診開始的太早之前介入,就沒有任何效用。在會診前介入或在會診開始一段時間前介入,都讓病人滿意度有小幅度的增加,但在統計上只有在會診前介入有顯著的意義。從介入協助病人來看臨床醫師的訓練,因為證據受限,並沒有發現明顯的效果。

作者結論

設計在診察前介入協助病人,以滿足他們在資訊上的需求,在目前證據中對病人的好處有限。進一步的研究可以探討病人詢問問題的品質是否有提升?是否可以降低診察前病人的焦慮?對其他結果的影響以及對訓練跟介入時機的衝擊。需要更多研究以評估介入的時機以及提供給臨床醫師的訓練方式。

翻譯人

本摘要由成功大學附設醫院蔡佩蓉翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

在醫療診察前介入,以協助病人獲得他們所需要的資訊。病人通常表示他們想要從醫護人員那裡得到更多的資訊,或是表示所接收到的訊息無法滿足他們的需求。一般來說,提供給病人的資訊很少。而一般人對不同的疾病,在資訊上也有不同的需求。給予病人足夠的資訊是很重要的,因為可以協助病人回想、瞭解並遵守治療建議,也可以讓病人更滿意。臨床醫師可能低估或忽視病人對資訊的需求,也可能缺乏有效給予病人資訊的技巧。培訓醫師和護士可能有用,但也可以試著直接協助病人在診察時發問。有很多種方法可以改善這種情形,就像問題提示表單(question prompt sheets ,鼓勵病人將想要問的問題寫在紙上),或者從旁輔導(在一旁協助並提示病人去思考想要問的問題)。這篇評論就是評估各種介入措施的研究。我們一共確認了33個隨機對照臨床試驗,納入了來自6個診間環境不同的國家,但主要是美國的8244位病人。大多介入措施,包含書面資料(例如:問題提示表單)以及從旁輔導,都在診察前的候診室中進行。被拿來跟無效的介入措施或一般常規照護做比較。健康議題包含:基層醫療(primary care) 以及家庭醫學(family medicine)、癌症、糖尿病、心臟疾病、女性相關議題、消化性潰瘍以及精神方面疾病。我們發現在發問以及病人滿意度方面,有小幅度的增加,而病人的焦慮,在診察前後有可能降低。我們同時發現到,在病人知識方面有可能減少,而在會診時間上有可能小幅度的增加。從旁引導以及書面資料都可產生類似的效用,但是以病人的觀點來看,從旁引導對病人滿意度來說,是比較有幫助的。在診察前一刻才介入協助病人,對病人滿意度而言,是有小幅度的增加,反而在診察一段時間之前就介入協助病人,並沒有這個效果。在診察一段時間前介入協助病人,並不會影響會診的時間,特別是使用書面資料比從旁引導影響較大。在診察前先介入協助病人,並不會影響會診的時間,而且好像可以協助病人在會診時,提出更多問題,但除此之外,並沒有其他明顯的好處。醫師和護士需要繼續試著去協助病人在會診中發問,在某些情況下或許可以使用提示的表格,或以從旁引導的方式協助病人。

Plain language summary

Interventions before healthcare consultations for helping patients get the information they require

Patients often report that they want more information from their healthcare providers or that the information they do receive does not address their needs. Generally, the amount of information given is small. People have differing needs for information, which also varies with the specific illness, but providing information is important as it helps patients recall, understand and follow treatment advice and be more satisfied. Clinicians may underestimate or undervalue the information needs of patients. They may also lack the skills to give information effectively. Training doctors and nurses probably helps, but another approach is to try to directly help patients ask questions in their consultations. This can be done by various methods such as question prompt sheets (which encourage patients to write down their questions) or coaching (when someone helps the patient to think of the questions they want to ask). This review evaluated studies of these types of interventions.

We identified 33 randomised controlled trials involving 8244 patients from six countries, mainly the USA, in a range of clinical settings. Most interventions, which included written materials (for example, question prompt sheets) and coaching sessions, were delivered in the waiting room immediately before the consultation. They were compared to dummy interventions or usual care. Health issues included primary care and family medicine, cancer, diabetes, heart problems, women's issues, peptic ulcer and mental illness.

We found small increases in question asking and patient satisfaction and a possible reduction in patient anxiety before and after consultations. We also found a possible reduction in patient knowledge and a possible small increase in consultation length. Both coaching and written materials produced similar effects on asking questions but coaching had a larger benefit in terms of patient satisfaction. Interventions immediately before the consultation led to a small increase in patient satisfaction whereas giving the intervention some time before did not. Interventions immediately before the consultation also resulted in small increases in consultation length, particularly when using written materials rather than coaching. Interventions some time before the consultation did not alter consultation time.

The interventions seem to help patients ask more questions in consultations, but do not have other clear benefits. Doctors and nurses need to continue to try to help their patients ask questions in consultations and question prompt sheets or coaching may help in some circumstances.

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