Measuring change over time: assessing the usefulness of evaluative instruments.

Problems may arise when healthcare providers focus on managing diseases rather than on people and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. The authors updated a 2001 systematic review of the effects of these training interventions for healthcare providers that aim to promote patient-centred care in clinical consultations.
They found 29 new randomized trials (up to June 2010), bringing the total of studies included in the review to 43. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma.
These studies showed that training providers to improve their ability to share control with patients about topics and decisions addressed in consultations are largely successful in teaching providers new skills. Short-term training (less than 10 hours) is as successful in this regard as longer training. Results are mixed about whether patients are more satisfied when providers practice these skills. The impact on general health is also mixed, although the limited data that could be pooled showed small positive effects on health status. Patients' specific health behaviours show improvement in the small number of studies where interventions use provider training combined with condition-specific educational materials and/or training for patients, such as teaching question-asking during the consultation or medication-taking after the consultation. However, the number of studies is too small to determine which elements of these multi-faceted studies are essential in helping patients change their healthcare behaviours.

Interventions for providers to promote a patient‐centred approach in clinical consultations

Interventions for providers to promote a patient-centred approach in clinical consultations. A systematic review.

Part V. The Underlying Framework: 13. A minimal theory of social transfers 14. A guide to the tests Part VI. Accounting for Social Spending, Jobs and Growth: 15. Explaining the rise of mass public schooling 16. Explaining the rise of social transfers 17. What drove postwar social spending? 18. Social transfers hardly affected growth 19. Reconciling unemployment and growth in the OECD Appendices.

Growing Public: Social Spending and Economic Growth Since the Eighteenth Century

Background
Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity.

Objectives
To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual.

Search methods
We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies.

Selection criteria
Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting.

Data collection and analysis
Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types.

Main results
We identified 18 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 12 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) −2.23, 95% confidence interval (CI) −2.52 to −1.95). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence) although two studies that specifically targeted functional difficulties in participants had positive effects on functional outcomes with one of these studies also reporting a reduction in mortality at four year follow-up (Int 6%, Con 13%, absolute difference 7%). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited.

Authors' conclusions
This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings

A mental health enterprise may be described by either (a) rather general philosophical total mental health goals, or (b) highly diverse and individualized patient-therapist goals. Goals a. have not provided a workable framework for program evaluation. This paper proposes that evaluation be done in the framework of goals b. by setting up, before treatment, a measurable scale for each patient-therapist goal, and specifying, for each patient, a transformation of his overall goal attainment into a standardized T-score. This method, together with random assignment of patients to treatment modes, was devised to permit comparison of treatment modes within a program, but it also provides a good basis for a judgmental evaluation of the total program.

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Goal attainment scaling: A general method for evaluating comprehensive community mental health programs

We report clinical data on the efficacy of acupuncture for alcohol dependence. 503 patients whose primary substance of abuse was alcohol participated in this randomized, single blind, placebo controlled trial. Patients were assigned to either specific acupuncture, nonspecific acupuncture, symptom based acupuncture or convention treatment alone. Alcohol use was assessed, along with depression, anxiety, functional status, and preference for therapy. This article will focus on results pertaining to alcohol use. Significant improvement was shown on nearly all measures. There were few differences associated with treatment assignment and there were no treatment differences on alcohol use measures, although 49% of subjects reported acupuncture reduced their desire for alcohol. The placebo and preference for treatment measures did not materially effect the results. Generally, acupuncture was not found to make a significant contribution over and above that achieved by conventional treatment alone in reduction of alcohol use. D 2002 Elsevier Science Inc. All rights reserved.

Regular article A large randomized placebo controlled study of auricular acupuncture for alcohol dependence

A large randomized placebo controlled study of auricular acupuncture for alcohol dependence.

Minnesota Orchestra members (42 males, 18 females) aged 24 to 64 years, all asymptomatic for hearing problems or ear disease, were evaluated with a hearing history questionnaire, otolaryngologic examination, and pure tone audiometry for the conventional (0.25 to 8 kHz) and extended high frequency (9 to 20 kHz) ranges. Hearing sensitivity was examined with respect to musician instrument type, years of playing, and orchestral stage position. Type of instrument played and position on the orchestral stage had no significant correlation with hearing loss.

Effects of instrument type and orchestral position on hearing sensitivity for 0.25 to 20 kHz in the orchestral musician.

Sixty members of the Minnesota Orchestra (aged 24 to 64 years) and 30 nonmusicians (aged 20 to 69 years) were evaluated for hearing sensitivity within the conventional audiometric range (0.25 to 8 kHz) and within the extended high frequency audiometric range (9 to 20 kHz). Threshold data were evaluated by age, sex, and musician-nonmusician categories for the respective frequencies, and data were compared to other studies. Musician hearing appeared no poorer than nonmusician hearing, suggesting no major hearing loss from musicians' exposure to orchestral noise. Hearing acuity of the two groups was similar to some normal groups reported in the world literature but appeared poorer in comparison to some normal groups defined by a very restrictive definition of normal hearing. Issues relating to the definition of normal hearing are explored. A mathematical model descriptive of extended high tone hearing sensitivity for musicians and nonmusicians evaluated was calculated. The formula is presented from which typ...

Robert E. Sherman

Papers

Goal attainment scaling: A general method for evaluating comprehensive community mental health programs

Regular article A large randomized placebo controlled study of auricular acupuncture for alcohol dependence

A large randomized placebo controlled study of auricular acupuncture for alcohol dependence.

Effects of instrument type and orchestral position on hearing sensitivity for 0.25 to 20 kHz in the orchestral musician.

Extended high frequency hearing sensitivity: a normative threshold study in musicians