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Biomedical subjects

Richard Thomson

Publications and source records attributed to Richard Thomson.

At least 19 recordsLinked to original sources
PubMed2007

Medical communication and technology: a video-based process study of the use of decision aids in primary care consultations.

BACKGROUND: Much of the research on decision-making in health care has focused on consultation outcomes. Less is known about the process by which clinicians and patients come to a treatment decision. This study aimed to quantitatively describe the behaviour shown by doctors and patients during primary care consultations when three types of decision aids were used to promote treatment decision-making in a randomised controlled trial. METHODS: A video-based study set in an efficacy trial which compared the use of paper-based guidelines (control) with two forms of computer-based decision aids (implicit and explicit versions of DARTS II). Treatment decision concerned warfarin anti-coagulation to reduce the risk of stroke in older patients with atrial fibrillation. Twenty nine consultations were video-recorded. A ten-minute 'slice' of the consultation was sampled for detailed content analysis using existing interaction analysis protocols for verbal behaviour and ethological techniques for non-verbal behaviour. RESULTS: Median consultation times (quartiles) differed significantly depending on the technology used. Paper-based guidelines took 21 (19-26) minutes to work through compared to 31 (16-41) minutes for the implicit tool; and 44 (39-55) minutes for the explicit tool. In the ten minutes immediately preceding the decision point, GPs dominated the conversation, accounting for 64% (58-66%) of all utterances and this trend was similar across all three arms of the trial. Information-giving was the most frequent activity for both GPs and patients, although GPs did this at twice the rate compared to patients and at higher rates in consultations involving computerised decision aids. GPs' language was highly technically focused and just 7% of their conversation was socio-emotional in content; this was half the socio-emotional content shown by patients (15%). However, frequent head nodding and a close mirroring in the direction of eye-gaze suggested that both parties were active participants in the conversation CONCLUSION: Irrespective of the arm of the trial, both patients' and GPs' behaviour showed that they were reciprocally engaged in these consultations. However, even in consultations aimed at promoting shared decision-making, GPs' were verbally dominant, and they worked primarily as information providers for patients. In addition, computer-based decision aids significantly prolonged the consultations, particularly the later phases. These data suggest that decision aids may not lead to more 'sharing' in treatment decision-making and that, in their current form, they may take too long to negotiate for use in routine primary care.

Aged↗
PubMed2006

Patients experience with long-term percutaneous endoscopic gastrostomy feeding following primary surgery for oral and oropharyngeal cancer.

Percutaneous endoscopic gastrostomy feeding (PEG) has an important role in providing nutritional support in selected patients undergoing treatment for oral and oropharyngeal cancer. Although morbidity data have been published there is very little from the patient perspective. The aim of this project was to devise, pilot and survey a PEG specific questionnaire and relate outcomes to health-related quality of life. A cross-sectional survey was conducted in April 2005 of patients who were alive and disease free and treated by primary surgery for oral and oropharyngeal squamous cell carcinoma between 1992 and June 2004. The survey comprised the University of Washington Quality of Life questionnaire and a 24 item PEG questionnaire. Of 344 alive and disease free patients, 243 (71%) responded. Clinical characteristics of responders and non responders were similar. Mean age of responders was 65 (SD 12) and 59% were male. There were 193 (79%) patients who never had a PEG as part of their treatment, 30 (12%) who had their PEG removed (median 7 months), and 20 (8%) who still had a PEG (median 34 months). Patients with PEGs reported significant deficits in all UW-QOL domains compared to non-PEG or PEG-removed patients and also reported a much poorer quality of life. The major PEG related problems were not those of discomfort, leakage or blockage, but interference with family life, intimate relationships, social activities, and hobbies. More can be done to counsel and support patients with long-term PEG placement.

Aged↗
PubMed2006

Developing a quality criteria framework for patient decision aids: online international Delphi consensus process.

OBJECTIVE: To develop a set of quality criteria for patient decision support technologies (decision aids). DESIGN AND SETTING: Two stage web based Delphi process using online rating process to enable international collaboration. PARTICIPANTS: Individuals from four stakeholder groups (researchers, practitioners, patients, policy makers) representing 14 countries reviewed evidence summaries and rated the importance of 80 criteria in 12 quality domains on a 1 to 9 scale. Second round participants received feedback from the first round and repeated their assessment of the 80 criteria plus three new ones. MAIN OUTCOME MEASURE: Aggregate ratings for each criterion calculated using medians weighted to compensate for different numbers in stakeholder groups; criteria rated between 7 and 9 were retained. RESULTS: 212 nominated people were invited to participate. Of those invited, 122 participated in the first round (77 researchers, 21 patients, 10 practitioners, 14 policy makers); 104/122 (85%) participated in the second round. 74 of 83 criteria were retained in the following domains: systematic development process (9/9 criteria); providing information about options (13/13); presenting probabilities (11/13); clarifying and expressing values (3/3); using patient stories (2/5); guiding/coaching (3/5); disclosing conflicts of interest (5/5); providing internet access (6/6); balanced presentation of options (3/3); using plain language (4/6); basing information on up to date evidence (7/7); and establishing effectiveness (8/8). CONCLUSIONS: Criteria were given the highest ratings where evidence existed, and these were retained. Gaps in research were highlighted. Developers, users, and purchasers of patient decision aids now have a checklist for appraising quality. An instrument for measuring quality of decision aids is being developed.

Decision Support Techniques↗
PubMed2006

Measurement of the safety and quality of health care.

Measurement of safety and quality is fundamental to health care delivery. A variety of measures are needed to fully understand the system; quantitative and qualitative measures are both useful in different ways. Measures need to be valid, reliable, accurate, timely, collectable, meaningful, relevant and important to those who will use them. Clinicians value appropriate measures and respond to them.

Australia↗
PubMed2006

Patients' preference for involvement in medical decision making: a narrative review.

OBJECTIVE: This review aimed to clarify present knowledge about the factors which influence patients' preference for involvement in medical decision making. METHODS: A thorough search of the literature was carried out to identify quantitative and qualitative studies investigating the factors which influence patients' preference for involvement in decision making. All studies were rigorously critically appraised. RESULTS: Patients' preferences are influenced by: demographic variables (with younger, better educated patients and women being quite consistently found to prefer a more active role in decision making), their experience of illness and medical care, their diagnosis and health status, the type of decision they need to make, the amount of knowledge they have acquired about their condition, their attitude towards involvement, and the interactions and relationships they experience with health professionals. Their preferences are likely to develop over time as they gain experience and may change at different stages of their illness. CONCLUSION: While patients' preferences for involvement in decision making are variable and the process of developing them likely to be highly complex, this review has identified a number of influences on patients' preference for involvement in medical decision making, some of which are consistent across studies. PRACTICE IMPLICATIONS: By identifying the factors which might influence patients' preference for involvement, health professionals may be more sensitive to individual patients' preferences and provide better patient-centred care.

Decision Making↗
PubMed2006

Decision support for health care: the PROforma evidence base.

Cancer Research UK has developed PROforma, a formal language for modelling clinical processes, along with associated tools for creating decision support, care planning, clinical workflow management and other applications. The PROforma method has been evaluated in a variety of settings: in primary health care (prescribing, referral of suspected cancer patients, genetic risk assessment) and in specialist care of patients with breast cancer, leukaemia, HIV infection and other conditions. About nine years of experience have been gained with PROforma technologies. Seven trials of decision support applications have been published or are in preparation. Each of these has shown significant positive effects on a variety of measures of quality and/or outcomes of care. This paper reviews the evidence base for the clinical effectiveness of these PROforma applications, and previews the CREDO project -- a multi-centre trial of a complex PROforma application for supporting integrated breast cancer care across primary and secondary care settings.

Breast Neoplasms↗
PubMed2005

Doctor-patient interaction in a randomised controlled trial of decision-support tools.

In this paper, we draw on the analytic perspectives of ethnomethodology to explore doctor-patient encounters in an experimental trial of a complex intervention: an efficacy randomised controlled trial (RCT) of decision-support tools in the UK. We show how the experimental context in which these encounters take place pervades the interactions within them. We argue that two interactional orders were at work in the encounters that we observed: (i) the ceremonial order of the consultation and (ii) the assemblage of the decision-support tool trial. We demonstrate how doctors in the trial oscillate between positions as authoritative clinician and neutralistic decision-support tool-implementer, and patients move between positions as passive recipients of clinical knowledge and as active subjects required to render their experience as calculable in terms of the demands of the decision-support tools and the broader trial they are embedded in. We demonstrate how the RCT coordinates the world of the clinical environment and the world of experimental evidence.

Decision Support Systems, Clinical↗
PubMed2005

Patients or research subjects? A qualitative study of participation in a randomised controlled trial of a complex intervention.

OBJECTIVE: To explore participants' understandings regarding treatment decisions, made within an efficacy randomised controlled trial (RCT) of decision-support tools. METHODS: Qualitative study: interviews (audio-recorded) with participants. Participants were interviewed 3-5 days after using a decision-support tool (n=30) and again at 3 months (n=26). Transcripts were analysed using a constant comparative approach. RESULTS: Participants' understandings were shaped by the ways in which they made sense of their participation. Participants made attributions about their trial identity that fell on a continuum. At one end we found participants who identified as 'experienced medical volunteers', and at the other those who identified as 'real patients'. In the participants' accounts, a trial identity of 'patient' accompanied an expectation that the decision-support tools offered a means of making treatment decisions. 'Volunteers', however, saw the interventions as tasks to be completed for the purposes of the trial team. CONCLUSION: In our study, trial identity shaped participants' understandings regarding treatment decisions and all other aspects of the trial. PRACTICE IMPLICATIONS: Different understandings regarding the appropriate response to trial tasks may affect behaviour and therefore outcomes in some trials. Further research is required to unravel the relationship between trial identities, understanding and behaviour.

Altruism↗
PubMed2004

Assessing patients' preferences for treatments for angina using a modified repertory grid method.

A current popular theme in medicine concerns whether and how patients should be involved in treatment choice. Assuming patient involvement is desirable, how should one go about eliciting preferences? A variety of quantitative and qualitative methods exist that may be used for this purpose, one of which is the repertory grid method. This method involves eliciting constructs (reasons) for preferences through comparing sets of three options. This method allows the structured elicitation of the reasons behind individual preferences, but also, when used with generalised procrustes analysis (GPA), allows aggregation of individual data to reveal general preference patterns. In this study the repertory grid method was used to examine patient preferences for angina treatments with the goal of, first, gaining some understanding of general patterns of patient preference, and second, examining the likely utility of the technique in this setting. A sample of 21 patients with mild and stable angina from two general practices in Norfolk, UK was interviewed using the repertory grid method to elicit the constructs underlying their preferences amongst seven angina treatments (including 'no treatment'). Individualised questionnaires were then produced and sent to the patients for self-completion, which required rating the extent to which each construct was relevant for each treatment (scored on visual analogue rating scales). Analysis of the ratings, using GPA, showed that the constructs clustered around two dimensions: 'some treatment' versus 'no treatment', and drug treatment versus surgical treatment. While some treatment was generally preferred to no treatment, individuals varied in preference for drug treatments or surgical treatments. Although the latter were generally perceived as 'effective' they were also perceived, for example, as 'invasive', 'frightening', related to 'negative experiences', and being more appropriate for when symptoms are severe ('proportionate'). We consider the implications of these results for involving patients in choosing amongst treatments.

Adult↗
PubMed2004

Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma.

The history of monitoring the outcomes of health care by external agencies can be traced to ancient times. However, the danger, now as then, is that in the search for improvement, comparative measures of mortality and morbidity are often overinterpreted, resulting in judgments about the underlying quality of care. Such judgments can translate into performance management strategies in the form of capricious sanctions (such as star ratings) and unjustified rewards (such as special freedoms or financial allocations). The resulting risk of stigmatising an entire institution injects huge tensions into health-care organisations and can divert attention from genuine improvement towards superficial improvement or even gaming behaviour (ie, manipulating the system). These dangers apply particularly to measures of outcome and throughput. We argue that comparative outcome data (league tables) should not be used by external agents to make judgments about quality of hospital care. Although they might provide a reasonable measure of quality in some high-risk surgical situations, they have little validity in acute medical settings. Their use to support a system of reward and punishment is unfair and, unsurprisingly, often resisted by clinicians and managers. We argue further that although outcome data are useful for research and monitoring trends within an organisation, those who wish to improve care for patients and not penalise doctors and managers, should concentrate on direct measurement of adherence to clinical and managerial standards.

Critical Care↗
PubMed2004

How research-conscious GPs make decisions about anticoagulation in patients with atrial fibrillation: a qualitative study.

BACKGROUND: Delays in the implementation of research findings have been of particular concern during the last decade. New findings, such as the use of warfarin to prevent stroke in patients with atrial fibrillation, have been found to be implemented patchily in clinical practice, in both primary and secondary care. OBJECTIVE: The purpose [corrected] of the study was to explore how GPs with an active interest in research or evidence-based medicine (EBM) make decisions about anticoagulation in patients with atrial fibrillation. METHODS: Semi-structured interviews with GPs about their experiences in managing patients with atrial fibrillation were recorded on audio-tape, transcribed and analysed using the 'Framework' method. A constructivist approach was taken to analysis and interpretation. RESULTS: Eleven interviews were included in the analysis. Two key themes, 'evidence' and 'professional role', were identified. No two respondents had the same perception of the evidence, which was influenced by experience, attitudes and a variable knowledge of the literature. Recent publications about the effectiveness of aspirin compared with warfarin, and the publication Clinical Evidence were the most frequently mentioned sources of evidence. GPs with confidence in EBM skills described giving highly detailed explanations to patients and having a great commitment to shared decision making, even if this resulted in patients declining treatment. For this reason, they also expressed antagonism towards prescriptive clinical guidelines. Hospital doctors were seen as exerting a powerful influence on decisions, as being 'disease-centred', difficult to challenge and poor at communicating. CONCLUSIONS: Decision making about anticoagulation is complex and is determined by a socially constructed view of the evidence strongly influenced by the GP's professional role.

Adult↗
PubMed2004

UK Quality Indicator Project (UK QIP) and the UK independent health care sector: a new development.

PURPOSE: To describe implementation of the UK Quality Indicator Project (UK QIP) in the independent health care sector, drawing upon 10 years experience in the UK and approaching 20 years experience in the USA. We describe the history of the project, with an emphasis on recent developments, reflecting upon the critical features of the project and its value for participants. BACKGROUND: The International Quality Indicator Project is the largest international data set of quality indicators. It provides participants with quarterly feedback of comparative indicator data and support for effective use of these data within the participants' own quality improvement programmes. The UK QIP now includes about two-thirds of UK private sector acute hospitals. The UK QIP began as a pilot project in the National Health Service (NHS) public sector in 1991. Implementation of the NHS performance assessment framework, and associated indicator programme, led to a reduction in public sector involvement. In contrast, the private sector, led by the Independent Healthcare Association, sought to identify a provider of key performance indicators to support both internal, within-sector drives for quality improvement and external demands produced by governmental review and the introduction of the National Care Standards Commission. The UK QIP was chosen since it provided a validated, epidemiologically sound system with capacity for support, education and flexibility to meet the changing demands of the sector. The future development of the QIP within the sector, including expansion from acute hospitals to mental health, is described. CONCLUSIONS: Reflection on the process of engagement of the UK independent sector with the QIP emphasizes the generic nature of the project and offers insights into the value of the project. Future challenges, including the issue of public accountability, are discussed in light of the project's underlying philosophy and purpose.

Private Sector↗
PubMed2004

Reasons underpinning patients' preferences for various angina treatments.

OBJECTIVE: To elicit patients' preferences for the treatment of angina. DESIGN: Angina patients were interviewed in order to elicit their personal reasons underlying preferences for various treatment options. Interviews followed a general repertory grid technique, in which seven treatment options were presented to patients in triads. Treatments considered ranged from medication to invasive revascularization therapies, with a 'no treatment' option. SETTING: Two general practices in Norwich, Norfolk. SUBJECTS: Twenty-one patients with diagnosed angina, which was both mild and stable. MAIN OUTCOME MEASURES: Treatment preferences verbalized by patients during interview, and the underlying reasons for these. RESULTS: Attitudes voiced towards the range of treatments for angina were diverse; 27 different reasons underlying patients' preferences were identified. Patients' preferences were largely justified by reasons associated with the conditional effectiveness or otherwise of treatments. When presented with treatment triads, medication (drug) treatments were over 2.5 times more likely to be chosen as a most preferred option than invasive or surgical treatments. Although surgical treatments were generally considered to be 'effective', it was perceived that they were more appropriate for situations when the condition became life-threatening. There were occasions, however, when preferences were driven by other reasons, such as a desire to avoid surgery because it was perceived negatively as 'invasive' and 'frightening'. Drug treatments were viewed as 'quick', 'easy' and reversible. Personal experiences of the effectiveness or otherwise of treatments were frequently cited as reasons for stated preferences. However, patients often commented that they would prefer the doctor to make the decision about their treatment. CONCLUSIONS: Patients choices among treatments was largely driven by perceptions of their effectiveness or otherwise. Although surgery was perceived as 'effective' it was also seen as conditionally so, dependent upon severity of the condition - which is not necessarily the case, as the risks of adverse events and surgical complications increase for emergency cases. As such, access to better information about the effectiveness and timeliness of interventions is needed. Although respondents held anxieties about treatment, particularly invasive or surgical treatments, fewer choices were driven by emotional and lifestyle factors unrelated to 'effectiveness', such as fear or ease of treatment.

Adult↗
PubMed2004

Validation of a method to establish practice-based stroke and TIA registers.

This study compares two methods to establish stroke and transient ischaemic attack (TIA) practice-based registers, which are of particular relevance to practices with limited diagnostic coding. Both arms involved a notes review of all patients taking antiplatelets or anticoagulants, and, either a further notes review of all patients with ischaemic heart disease (IHD) or diabetes (extensive arm), or asking about a history of stroke or TIA during IHD or diabetic clinics (pragmatic arm). The extensive arm involved searching 11% of the practice notes, whereas the pragmatic arm only involved 3% and had almost as high a yield. This study suggests that the pragmatic method could be used to help build practice-based stroke and TIA registers.

Aged↗
PubMed2003

Risk factors for first-ever stroke in older people in the north East of England: a population-based study.

BACKGROUND AND PURPOSE: Although older people potentially have most to gain from prevention, they have been excluded from or underrepresented in many stroke incidence studies. We sought to determine the risk factors for stroke in older people. METHODS: A 5-year follow-up study of a population-based cohort of 4440 subjects aged >65 years in northern England. Subjects were recruited from 27 general practices between 1995 and 1997. RESULTS: A total of 329 out of 4351 subjects with follow-up data suffered a first-ever stroke. On multivariate analysis, risk factors for stroke in older people included atrial fibrillation (hazard ratio [HR], 2.03 [95%CI, 1.31 to 3.16]); previous transient ischemic attack (1.87 [95% CI, 1.27 to 2.76]); smoking (1.72 [95% CI,1.28 to 2.32]); and cardiovascular disease (1.55 [95% CI, 1.19 to 2.03]). The HR per 10-mm Hg increase in systolic blood pressure was 1.15 (95% CI, 1.06 to 1.24). Age was associated with a HR of 1.74 (95% CI, 1.42 to 2.12) per 10-year increase. CONCLUSIONS: "Classic risk factors" increase the risk of stroke in older people. Stroke is not an inevitable consequence of aging, so by identifying and modifying risk factors in older people there are opportunities to reduce the incidence and mortality of this devastating condition.

Age Factors↗