Treatment of functional somatic symptoms in general practice
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Transcript of Treatment of functional somatic symptoms in general practice
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Research Unit for General Practice
University of Aarhus [email protected]
Treatment of functional somatic symptoms in
general practice
Marianne Rosendal, GP, PhDResearch Unit for General Practice, Aarhus
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Research Unit for General Practice
University of Aarhus [email protected]
Outline
Background about FSS The intervention Project design and measures Results Conclusion
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Research Unit for General Practice
University of Aarhus [email protected]
Definitions of FSS
Physical symptoms that lack an obvious organic basis (Mayou 1991)
Conditions where the patient complains of physical symptoms that cause excessive worry or discomfort or lead the patient to seek treatment but for which no adequate organ pathology or patho-physiological basis can be found (Fink 2002)
ICD-10: Somatoform DisordersPhysical symptoms and persistent requests for medical investigations, in spite of negative findings and reassuranceDuration > 6 months (WHO)
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Research Unit for General Practice
University of Aarhus [email protected]
Chronicsomatisation
Mild-moderate functional somatic symptoms
Normal physiological phenomena
FSS in primary careA spectrum of disorders
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Chronicsomatisation
Mild-moderate functional somatic symptoms
Normal physiological phenomena
FSS in primary careA spectrum of disorders
Consults the GP
SymptomsConditionsDisorders
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FSS - prevalence in primary care60-74% of common physical symptoms remain unexplained
20-30% fulfil ICD-10criteria for somatoformdisorders
6-10%chronicsomatisationdisorder
Kroenke 1989Fink 1999Toft 2004
Toft 2004de Waal 2004Fink 1999
Toft 2004Fink 1999
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Research Unit for General Practice
University of Aarhus [email protected]
Why intervention in primary care?
High prevalence of MUS Current (biomedical) treatment is
insufficient (Fink 1997, Salmon 1999, Barsky 2001)
GPs are frustrated about lacking knowledge and skills (Reid 2001)
Specialised care resources are limited
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Research Unit for General Practice
University of Aarhus [email protected]
Basis for the treatment programme
Cover the spectrum of disorders Tailored for general practice No involvement of specialists The intervention included
Evidence about various aspects of FSS Evidence on the treatment of FSS
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The Extended Reattribution and Management ModelThe Extended Reattribution and Management Model
Also available on www.auh.dk/CL_psych/uk/
P. Fink, M. Rosendal, T. Toft
Psychosomatics 2002Psychosomatics 2002; ; 43 (2): 93-13143 (2): 93-131
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Research Unit for General Practice
University of Aarhus [email protected]
TERM Model - objectives
Improve GP attitude, knowledge and skills
Concerning assessment and treatment
Of the whole spectrum of MUS
Acceptable programme to ALL GPs
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Research Unit for General Practice
University of Aarhus [email protected]
TERM Model - content
1. Understanding2. The physician’s expertise and
acknowledgement of illness3. Negotiating a new model of
understanding4. Negotiating further treatment
Follow-up appointments Management of chronic somatisation
Interviewing techniques from cognitive
behavioural therapy
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Research Unit for General Practice
University of Aarhus [email protected]
TERM Model – training programme
• Residential course 2 x 8 hours
Theory, micro skills training, video supervision, small group discussions
• Follow-up meetings, weekly 4 x 2 hours
• Booster meeting after 3 months 2 hours
• Outreach visit after 6 months ½ hour
In total 27 hours
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Research Unit for General Practice
University of Aarhus [email protected]
Evaluation – study design
RCT Two-step sampling
Practices/GPs Patients with FSS
Intervention Training at GP level TERM-model at patient level – provided
by trained GP Primary outcome at patient level
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Research Unit for General Practice
University of Aarhus [email protected]
Material
Vejle County Year 2000-2003 37-40 GPs from 21-24 practices Practices randomised 2880 patients included 911 patients had a high score for
somatisation (SCL-som, Whiteley-7) Follow-up: 1 year Evaluation based on questionnaires
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2214 patients registered 2256 patients registered
Inclusion
Control group13 / 20
Practices/GPs in Vejle County121 / 227
Participating practices/GPs27 (22%) / 43 (19%)
Blinded block randomisation of practices
Intervention group14 / 23
1542 patients included 1338 patients included
509 high score 407 high score
13 days registration of all patients aged 18-65 years and patient initiated consultations
InterventionIntervention
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Research Unit for General Practice
University of Aarhus [email protected]
Evaluation - outcome
Primary outcome Patients’ self-evaluated health (physical
functioning on SF-36) Secondary outcome
Patients’ satisfaction with care Intermediate measures
GPs’ “happiness index” GPs’ attitudes GPs’ classification
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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Structure of the course
The teaching
Theory sessions - contents
Theory sessions - teachers
Presentation of exercises - contents
Presentation of exercises - teachers
Exercises
Written presentation of exercises
Exercises with actor recorded on video
Exercises two and two
Video feedback as supervisee
Video feedback as group member
Supervisor
The TERM manual
Educational material folder
Quite bad
Bad
Average
Good
Very good
N = 120
GP evaluation of 6 TERM seminars
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Research Unit for General Practice
University of Aarhus [email protected]
GPs’ change in attitudes
“How do you typically react when you see a patient with somatoform disorder in your consultation?”
Example 7-point Likert scale
Not at all very much
I enjoy working with these patients ■ ■ ■ ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■
Hartmann 1989
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GPs’ change in attitudes
Difference=
12-month follow-up
baseline
values
*p=0,019
**p<0,01
-2 -1 0 1 2
Control (N=18) Intervention (N=22)
Difference on a 7-point Likert scale
Anger**
Anxiety**
Unsure*
Enjoyment**
Worry
Too much time
(Rosendal 2005)
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Research Unit for General Practice
University of Aarhus [email protected]
GPs’ classification
% of patients
0
10
20
30
40
50
60
70
80
Physicaldisease
Probablephysical
FSS Mentalillness
No physical symptoms
Control
Intervention
Combined analysisp=0,049
(Rosendal 2003)
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Research Unit for General Practice
University of Aarhus [email protected]
GPs’ classification
% of patients
0
10
20
30
40
50
60
70
80
Physicaldisease
Probablephysical
FSS Mentalillness
No physical symptoms
Control
Intervention
Combined analysisp=0,049
(Rosendal 2003)
Difference=4,0%p=0,007
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Research Unit for General Practice
University of Aarhus [email protected]
0
10
20
30
40
50
37 GPs
GP diagnostic rate
% p
osi
tive
of
incl
ud
ed p
atie
nts
Classification rate of FSS by GPs
(Rosendal 2003)
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Research Unit for General Practice
University of Aarhus [email protected]
0
10
20
30
40
50
37 GPs
GP diagnostic rate SCL-SOM or Whiteley-7 positive
% p
osi
tive
of
incl
ud
ed p
atie
nts
Classification rate of FSS by GPs
(Rosendal 2003)
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Research Unit for General Practice
University of Aarhus [email protected]
Evaluation - Patient Satisfaction% of ”FSS” patients with high satisfaction after 12 months
0
5
10
15
20
25
30
35
40
45
Doctor-patientrelationship
Medical-technicalcare
Informationand support
Control
Intervention
p=0,069p=0,237p=0,567
(n=600)
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Patient health
Mean
60
70
80
90
100
Inclusion 3 months 12 months
Control Intervention Danish population
p=0,890
SF-36 physical functioning (n=601-711)
Rosendal 2006
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Research Unit for General Practice
University of Aarhus [email protected]
Conclusion - results
The TERM model Is accepted by GPs Training of GPs induced
A sustained positive effect on GPs’ attitudes
Increased GP awareness of FSS A possible positive effect on patient
satisfaction No effect on patient health
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Research Unit for General Practice
University of Aarhus [email protected]
Problems encountered Intervention
How do we know whether the training or the model itself failed?
Which parts of the intervention could be improved? How did the setting affect the intervention? How does time influence desired behavioural changes in
the study (GPs and patients)? Sampling
How do we sample patients with FSS in general practice? How do we avoid inclusion bias in the practices
undergoing intervention? Outcome
How do we measure relevant patient outcome in relation to FSS?
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Research Unit for General Practice
University of Aarhus [email protected]
Thank you for your attention!