Releases Saturday 26 February 2000
No 7234 Volume 320

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(1) WELL MEANING ATTEMPTS TO REASSURE
PATIENTS CAN BACKFIRE

(2) OPEN ACCESS FOLLOW UP IS COST EFFECTIVE
AND POPULAR WITH GPS AND PATIENTS WITH
INFLAMMATORY BOWEL DISEASE

(3) MOST ASTHMA MANAGEMENT REVIEWS ARE
FLAWED, LIMITING THEIR VALUE FOR HARD
PRESSED DOCTORS

(4) CAUTION IS NEEDED IN COMMERCIAL
PARTNERSHIPS IN CARE MANAGEMENT




(1) WELL MEANING ATTEMPTS TO REASSURE
PATIENTS CAN BACKFIRE

(Qualitative study of interpretation of reassurance among
patients attending rheumatology clinics: "just a touch of
arthritis, doctor?")
http://www.bmj.com/cgi/content/full/320/7234/541

Providing reassurance to patients is a key medical task, yet
there is little evidence about the best ways to impart it
successfully. A qualitative study by Donovan and Blake at the
University of Bristol's Department of Social Medicine shows
that doctors' attempts to reassure rheumatology patients that
their symptoms are mild or that the disease is in its early
stages, can be counterproductive. Patients can be left with the
feeling that the doctor has not understood their problems and
with raised concerns about possible future pain and disability.

Writing in this week's BMJ, a theme issue devoted to the
management of chronic disease, the authors acknowledge
other studies which have found that patients and doctors
often have different perspectives on the same clinical
encounter. Whilst efforts have tended to focus on improving
the clarity of information provided to patients, Donovan and
Blake argue that the key to successful reassurance lies in the
doctor's ability to acknowledge patients' pain and
difficulties. By means of a qualitative study of tape recordings
of consultations and in-depth interviews with 35 patients from
two major British cities, the authors found that the doctors'
tendency to emphasise the non-seriousness of the condition
contrasted with the patient's own perception that their lives
had already been disrupted and led to heightened fears about
pain and disability in the future. The authors conclude that
doctors should avoid loaded terms such as "mild" and "early
stages" and, at the same time, try to understand and
acknowledge patients' views that their difficulties are serious
and require attention.

Contact:

Jenny Donovan, Reader in Social Medicine, Department of
Social Medicine, University of Bristol, Bristol BS8 2PR
Email: jenny.donovan@bris.ac.uk

(2) OPEN ACCESS FOLLOW UP IS COST EFFECTIVE
AND POPULAR WITH GPS AND PATIENTS WITH
INFLAMMATORY BOWEL DISEASE

(Open access follow up for inflammatory bowel disease:
pragmatic randomised trial and cost effectiveness study)
http://www.bmj.com/cgi/content/full/320/7234/544

Open access follow-up for patients with stable inflammatory
bowel disease delivers the same quality of care as routine
outpatient appointments, is preferred by patients and general
practitioners and would save the average consultant in
gastroenterology 25 - 50 outpatient visits per year. This is the
conclusion of a two-year long randomised trial and cost
effectiveness study conducted by J G Williams et al at the
School of Postgraduate Studies in Medical and Health Care,
at Morriston Hospital in Swansea, studying patients from
Morriston and Neath hospitals.

The patients registered a strong preference for open access,
feeling it appropriate to attend only when ill. General
practitioners also preferred open access but some patients
experienced difficulty in making urgent appointments.
Effective methods are needed to overcome this difficulty and
the favoured solution is the employment of a specialist nurse
practitioner to organise patient access.

Contact:

J G Williams, Director, School of Postgraduate Studies in
Medical and Health Care, Morriston Hospital, Swansea SA6
6NL
Email: john.williams@pgms.wales.nhs.uk

(3) MOST ASTHMA MANAGEMENT REVIEWS ARE
FLAWED, LIMITING THEIR VALUE FOR HARD
PRESSED DOCTORS

(Systematic reviews and meta-analyses on treatment of
asthma: critical evaluation)
http://www.bmj.com/cgi/content/full/320/7234/537

Hard pressed doctors trying to cope with the vast amounts of
information on new treatments for asthma would do well to
turn to the Cochrane reviews rather than those published in
peer-reviewed journals or funded by industry. The Cochrane
reviews are more rigorous and better reported than those
published in peer review journals, says an article in this
week's BMJ. All six of the reviews sponsored by industry
were found to have serious methodological flaws and five out
of six had results that favoured interventions related to the
companies sponsoring the reviews.

Alejandro Jadad et al of the Department of Clinical
Epidemiology and Biostatistics at McMaster University in
Hamilton, Canada subjected 50 clinical reviews to critical
evaluation using the Oxman and Guyatt index to measure
methodological quality. Of the 10 highest scoring reviews,
seven were published in the Cochrane Library. Dr Jadad,
who declares a competing interest as co-director of the
Canadian Cochrane Network and Centre, says most of the
reviews had methodological limitations which could easily
have been avoided. He recommends that peer reviewed
journals provide authors and peer reviewers with clear
reporting criteria and use the Internet to update or correct
previously published material. Industry sponsored research
demands particular vigilance, the authors conclude.

Contact:

A R Jadad, Department of Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, Canada L8N
3Z5
Email: jadada@fhs.mcmaster.ca

(4) CAUTION IS NEEDED IN COMMERCIAL
PARTNERSHIPS IN CARE MANAGEMENT

(Commercial partnerships in chronic disease management:
proceeding with caution)
http://www.bmj.com/cgi/content/full/320/7234/566

(Disease management in the American market)
http://www.bmj.com/cgi/content/full/320/7234/563

In this week's BMJ, Trisha Greenhalgh and colleagues from
Barnet Health Authority's Clinical Effectiveness Review
Group set out draft standards for use by public sector
organisations who are considering entering a partnership with
companies offering disease management packages. The
authors argue that in the "new Labour" climate of
co-operation between commercial and NHS interests, it may
be unrealistic to impose a blanket ban on relationships with
companies. It may be better simply to require all parties to be
explicit about potential conflicts of interest and use a rigorous
checklist of quality standards to develop a package which
attempts to meet the interests of all parties.

Thomas Bodenheimer, Clinical Professor at the Department
of Family and Community Medicine, University of California
at San Francisco, School of Medicine argues that commercial
disease management programmes may take needed money
away from actual caregiving in order to enhance companies'
profits.

Both the American and British papers conclude that although
disease management programmes show promise in improving
the care of patients with chronic illnesses, commercial disease
management may have damaging, unintended consequences
for healthcare systems. There is a transatlantic consensus that
health care institutions should resist the trend to outsource
disease management work to commercial companies and
instead set up in house programmes that help primary care
physicians do a better job.

Contact:

Trisha Greenhalgh, Senior Lecturer in primary health care,
Department of Primary Care and Population Sciences,
University College Medical School, London N19 3UA
Email p.greenhalgh@ucl.ac.uk

or

Thomas Bodenheimer, Department of Family and Community
Medicine, University of California at San Francisco, School
of Medicine, 1580 Valencia Street, Suite 201, San
Francisco, CA 94110, USA
Email: tbodie@earthlink.net


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