Family Practice Vol. 19, No. 3, 264-271
© Oxford University Press 2002
The final version of the Patient Perspective Survey (PPS): a new tool to improve consultation outcome and patient participation in general practice patients with complex health problems. Doctors' and patients' evaluation and guidelines for clinical use
Section of General Practice, Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, N-0217 Oslo and
b Department of Behavioural Sciences in Medicine, University of Oslo, Norway.
a Present address: The Norwegian Back Pain Network, Division of Medicine–KGR, Ullevål Hospital, N-0407 Oslo, Norway.
Lærum E, Steine S, Finckenhagen M and Finset A. The final version of the Patient Perspective Survey (PPS): a new tool to improve consultation outcome and patient participation in general practice patients with complex health problems. Doctors' and patients' evaluation and guidelines for clinical use. Family Practice 2002; 19: 264–271.
Received 20 February 2001; Revised 2 October 2001; Accepted 7 January 2002.
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Abstract |
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 Top Abstract IntroductionMethods including guidelines for...ResultsDiscussionAppendix: Detailed description...References |
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Background. The Patient Perspective Survey (PPS) is a new clinical communication tool designed to stimulate patient involvement in the management of complex health problems in general practice and to improve patient and doctor satisfaction with the consultation. The development of this final 38-item version of the PPS has been described elsewhere.
Objective. The aims of this article are to present recommendations for clinical use and how GPs and patients have evaluated this new tool.
Methods. The study material included 159 patients (78% females) with a mean age of 45 years, mainly presenting with longstanding musculoskeletal and psychosocial disorders, selected by 32 GPs. After the PPS-based consultation, both doctor and patient were asked to fill in evaluation forms.
Results. In as many as 55–85% of the consultations' various aspects, it was perceived by the GPs that the use of the survey helped (to some extent, much or very much) in achieving improved clinical communication and a constructive consultation. The most important elements appeared to be stimulation of positive interaction/processes and obtaining new and relevant information. Similar results were found regarding patient evaluation. There was significantly more positive doctor evaluation if the doctor–patient relationship had lasted less than 1 year, and if the patient agreed to prepare a ‘plan of action’ for a follow-up consultation. Guidelines for clinical use are presented.
Conclusion. We now regard the PPS to be completed for daily clinical use and believe that it has been shown to be a potent tool to improve consultation outcome in the large and challenging group of patients with complex health problems in general practice.
Keywords. Communication, complex health problems, consultation improvement, guidelines, patient perspective, questionnaire.
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Introduction |
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TopAbstractIntroductionMethods including guidelines for...ResultsDiscussionAppendix: Detailed description...References |
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A large proportion of patients in general practice present with complex health problems in terms of psychosocial and musculoskeletal disorders.1–3 It is well known that GPs often find the management of these patient categories to be problematic, and may perceive a lack of effective management options, reflected in terms such as ‘the heart sink patient'. This was the reason why we developed a new instrument in terms of a self-administered questionnaire designed to enhance the quality of clinical communication and patient participation in the management process.2,4
We previously have documented that there is a need for such a new tool and have described the initial development and user evaluation of a first comprehensive version.2 The basic idea of the Patient Perspective Survey (PPS) was positively received, as was the clinical application in terms of enhanced patient participation and focus on coping abilities. However, a need for a more condensed version, better defined indications for its use and guidelines for clinical application has been recognized. In another publication, we have reported on the further development including testing of psychometric properties, leading to a final 38-item version of the survey.5
The aims of this article are to present recommendations for clinical use of this completed version of the PPS along with evaluations by the GPs and the patients.
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Methods including guidelines for clinical use |
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TopAbstractIntroductionMethods including guidelines for...ResultsDiscussionAppendix: Detailed description...References |
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The study material included 159 patients selected by 32 GPs during October 1995 to March 1998. The GPs were affiliated to the Section of General Practice as teachers or they were known personally to one of the authors (EL): 90% were working in group practices; 72% were male doctors and 85% were specialists in general practice, which is fairly representative of GPs in Norway. Patients were given the PPS to fill in at home and then bring it back for the next consultation to discuss what had been answered. The questionnaire contained 54 items covering: patient perception of their health problems, everyday life situation, coping strategies and need for help.5 On separate forms, the GPs recorded the patients' main diagnoses, age and gender, other demographic background variables and duration of the main complaint (Table 1
). They also recorded how many years they had known the patient, the duration of the consultation and plans for follow-up consultations.
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After the consultation, both the GP and the patient filled in evaluation forms regarding how the questionnaire helped to: obtain new and important information; see connections between everyday life, coping and complaints; improve the doctor–patient relationship including communication; influence self-help; and how constructive the PPS-based consultation was perceived as being (Tables 2 and 3
). Completed forms were forwarded directly to the project leader (EL) in stamped addressed envelopes.
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Guidelines for use
Before the inclusion period started, 3-hour courses on how to perform the consultations and carry out the project according to guidelines were held for the GPs. They were instructed on the following (see Appendix for a detailed description):
- Purpose of using the PPS
- Target groups
- Introduction
- How to perform the PPS-based consultation
- Interpretation of answers
- How to proceed after the consultation.
Data analysis
The data analysis is equivalent to that described previously.5
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Results |
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Socio-demographic characteristics and recorded background variables of the 159 enrolled patients are shown in Table 1
(these parameters are used later to predict doctor and patient outcome evaluations). More than three-quarters of the patients were female and 82% of the whole patient group had had their main complaint for >1 year.
Consultation evaluation
Table 2 presents the doctors' evaluations of various aspects of the PPS-based consultations. In 55–85% of the consultations, the doctors found that the questionnaire had been helpful (to some extent, much or very much) in achieving its intended purposes, and in particular with respect to improved clinical communication and providing a constructive consultation. By applying factor analysis, two main and meaningful factors emerged. Factor 1, ‘process/interaction’, explained 57% of the total variance. Factor 2, ‘new information’, explained 12% of the variance.
In 81% of the consultations, an appointment was made for a follow-up consultation and 30% of the patients consented to prepare a ‘plan of action’.
Average consultation duration was 31.4 (SD 9.1) min. In 20% of the consultations, the doctor thought the survey contained too many questions.
By interviewing the participating GPs, and from the comments on the evaluation forms, a variety of supplementary and useful responses were found. The main issues commented upon were:
- New and important medical information: "I discovered a new psychiatric diagnosis important to know about", or "The patient's fear of having relapse of his cancer operated on 5 years ago is far more intense and important than I knew".
- Recognition of connections between everyday life situation and health problems: "The patient obtained profound and new insight into his relationship with his wife . . . a new chapter started".
- Focus on resources and coping: "The use of the PPS revealed a much better life situation and coping ability of the patient than I was aware of", and "The patient asks for help to improve self-image and coping strategies to reduce marital and job-related stress".
- Improved management/therapy: "Use of the PPS made me decide to treat his depression".
Negative comments were related mostly to the doctor's feeling that he or she knew the patient very well from a longstanding doctor–patient relationship, so nothing really new occurred by using the PPS.
Table 3 gives the patients' evaluations of the outcome of applying the PPS. For 63–82% of the various aspects of the consultation, the patients thought that the use of the survey contributed to some extent, much or very much to improved consultation-related processes. Most frequently this was associated with new information for the doctor, improved doctor–patient relationship/communication, positive effect on health and everyday situations as well as achieving a constructive consultation. In addition, two meaningful factors emerged from the factor analysis. The first factor ‘patient centred’ explained 57% of the total and the second factor ‘doctor centred’ explained 12% of the variance.
In 10% of the consultations, the patients thought the survey contained too many questions.
Comments on the forms were related mainly to:
- Getting a better overview and insight: "This is a very effective way for the doctor to get acquainted with the patient".
- Better management/problem solving: "This process really made contributions to a solution to my health problems".
Negative comments were as for those of the doctors, mainly connected to feeling of nothing new coming up: "My doctor has already posed these questions several times earlier, he knows everything about me and is doing the right things".
Bivariate analysis and prediction of evaluation outcome
In the bivariate analysis, doctors rated the ‘process/ interaction’ factor significantly higher in patients with good subjective health and a high level of education. There was no association between the doctors' evaluations and other socio-demographic variables, and no associations between background variables and patients' evaluations. No association was found between doctor or patient evaluation and the main diagnostic grouping or whether a follow-up consultation was arranged.
A significantly more positive doctor's evaluation was found when: the patient had been known to the doctor for less then 1 year (P < 0.0001); if the patient agreed to prepare a ‘plan of action’ (P < 0.0001); or where the patient had recognized a connection between their life situation and health problems on the main form. The duration (minutes) of the consultation was significantly longer (4– 5 min) when the doctors rated the consultation outcomes ‘process/interaction’ and ‘new information’ as positive.
In order to predict positive doctor and patient evaluations of the consultation outcome, the two factors ‘process/interaction’ and ‘patient centred’ were used respectively as dependent variables in a logistic regression model. Independent variables were dichotomized (see Table 1), as were the dependent variables (high scoring = above or equal to the mean). Variables showing statistically significant differences in their frequency distribution (Mantel–Haenszel test for linear association) were entered into a regression model.
A significant influence was demonstrated for the following variables: known the patient <1 year [odds ratio (OR) 6.7, P = 0.001]; ‘prepare a plan of action’ (OR 3.6, P = 0.3); improved communication (OR 3.8, P = 0.02); and a high level of education (OR 3.3, P = 0.003)
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Discussion |
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TopAbstractIntroductionMethods including guidelines for...ResultsDiscussionAppendix: Detailed description...References |
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The main objective of this project was to develop a new instrument designed to improve consultation outcome and patient participation in general practice patients with complex health problems. In 82–85% of the consultations, both the doctors and patients perceived that the use of the PPS was helpful (to some extent, much or very much) to achieve a constructive consultation. We consider this to be a highly satisfactory result. This is supported by the fact that the target patient group have complex and diffuse disorders where the GPs often experience limited effects of their usual management strategies, reflected in terms such as ‘the heart sink patient', ‘the difficult patient' or somatization disorders.1,4,6 In addition, we have many favourable comments on the forms and from the doctors' interviews.
We believe that an important factor explaining this result is the instrument's theoretical foundation with emphasis on patient centredness, participation and resources/coping.2 This is in line with the changing focus towards salutogenesis and away from medicalization.7,8 Another important aspect is probably related to the fact that we have developed the tool over quite a number of phases including several populations of patients and GPs who gave their responses with potentials for improvements of the tool.2,5 Additionally, we have applied recognized principles for questionnaire development.9–13
A main criticism of earlier versions of the PPS was its comprehensiveness which was too much to deal with during a busy general practice consultation, even if double the usual consultation time was provided.2 Regarding the 54-item PPS version used in the present study, it was perceived by both doctors and patients to contain too many questions in 20 and 10% of the consultations, respectively. As the completed version is reduced further now from 54 to 38 items (presented elsewhere), we believe that this problem has been largely overcome.5
An important methodological issue pertains to generalization of our study results, for instance to what extent the PPS may prove to be useful when applied to other (perhaps less enthusiastic) populations of doctors and patients in different cultural or practice settings, e.g. in countries where the GPs normally have much shorter consultations. Obviously, in order to make inferences, repeated studies are necessary. However, it is reassuring that an almost identical study among 21 Australian GPs has shown similar results to those in the present study.14
A further main criticism put forward by participants in previous PPS studies has been lack of sufficient precision of criteria for selection of suitable patients and guidelines for clinical use. This is the reason why, for instance, we have performed analyses to predict positive evaluation of the consultation outcome by both doctor and patient. The most important predictor was that the doctor had not known the patient for more than 1 year, demonstrated to be associated with a substantial difference in the odds ratio of obtaining a positive consultation outcome. This is also well in accordance with feedback from GPs during various stages of the survey development. Thus, if a long-lasting and perhaps close personal doctor–patient relationship has been established, it is less likely that any improvement in consultation outcome (including new information) or doctor–patient relationship will occur, and/or patients with long-lasting health problems may be less receptive to change.
The fact that patients with a higher level of education seem to have a better outcome than those with a lower level is as anticipated. The constructive use and positive outcome of the tool is an ‘intellectual manoeuvre’, which is easier to perform for those having a higher socio-economic status/education.
The finding of enhanced evaluation of the consultation outcome when a ‘plan of action’ was to be prepared seems logical and may be considered as an aid for the GP to facilitate patient participation and processes leading to ‘home lessons’.
Three important questions about the questionnaire that have been raised during the testing are to be addressed.
- The questionnaire does not focus only on specific health complaints/diseases, but on the patient's everyday situation and general coping strategies. Could this seem like inappropriate interference exceeding the GPs' ‘terms of reference’, which are sickness and health?
Many doctors will think that this depends on the situation. In some cases, we should be cautious in bringing to light conditions we can do nothing about. In other cases, it may be right (and in accordance with the patient's wishes) to emphasize that the patient is a person, with a biography, who lives in a context.15,16 It is the patient who, by visiting the doctor to get help for his/her health complaints, gives us our terms of reference. The doctor's task is to interpret these terms of reference wisely.
- What are the advantages of using the questionnaire, compared with a good talk that is ‘tailor made’ for the individual patient? In our opinion, nothing can replace this type of good consult-ation with one's own, personal doctor. The question has to be: are there situations where the questionnaire can supplement the ordinary way of working? It can happen that doctors, when looking through his journal, may realize that the contact has been rather ‘narrow’. Perhaps some important aspects have not been addressed. It may also happen that the doctor–patient relationship ‘gets into a rut’, and may need revitalizing. The questionnaire can change both the agenda and the pattern of communication.
- Is the questionnaire too comprehensive and time consuming to use in everyday practice? Using the questionnaire requires involvement and time. This applies to motivating the patient both when he/she is given the form, and at the follow-up consultation. The same applies to other clinical methods, for instance use of therapeutic supporting talks.17 In reality, GPs probably will not use the PPS often. Our point is not that this questionnaire should be used for a vast group of patients; but, when the doctor chooses to do so, it may often, as shown in the present study, be worth the time it takes. This is demonstrated by the fact that one-third of the patients had made a ‘plan of action’ with, for instance, focus on lifestyle or job changes, improvement of self-image or coping strategies or the relationship with significant others. When the patient did so, this was also associated with significant enhancement of the doctor's satisfaction with the consultation outcome.
In our view, the PPS concept is, in its basic foundation, construction and niche for application, unique, and represents a novel instrument for consultation improvement; it may be regarded as a complementary or alternative tool to other recent methods, such as, for example, an illness diary, to expand communication or development of key questions for female patients with diffuse disorders.18,19
A final basic question is whether the present PPS version can now be considered completed in its development? Our answer is yes. We regard it as completed and ready for clinical use. This does not mean, however, that further research is not warranted. Relevant research issues could be to: validate the PPS as a screening tool for psychiatric caseness; compare it with established instruments for measuring quality of life, health status, symptom profiles, social profiles or coping; perform randomized controlled trials to explore its effect on short- and long-term health outcome parameters; and further elaborate consultation techniques including follow-up procedures (e.g. psychotherapy, cognitive therapy or meditation).
In conclusion, we now regard the PPS as being completed for daily clinical use and it has been shown to be a potent and alternative tool that may improve consultation outcome and patient involvement in the large and challenging group of patients with complex health problems in general practice.
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Appendix: Detailed description of guidelines on how to use the PPS in daily practice |
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TopAbstractIntroductionMethods including guidelines for...ResultsDiscussionAppendix: Detailed description...References |
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1 Purpose of using the PPS
The PPS is a tool to be used in the efforts to help the patient with complex and perhaps long-lasting complaints. The survey is aimed at:
- Obtaining a shared overall picture and new/ relevant information of the patient's complaints, problems, everyday life and resources
- Helping both GP and patient (in a non-offensive manner) realize possible connections between the patient's health problems and his/her everyday situation
- Helping to change the patient's behaviour, attitudes and coping ability
- Redefining the patient's problems and contributing to a change of focus, ‘taking a new road’
- Initiating a shared plan of action (e.g. regarding lifestyle issues, relationship to job or significant other persons or coping strategy)
- Achieving an enhanced doctor–patient relationship and more effective communication and consultation outcome.
2 Target groups
From the development phases of the PPS, the following were shown to be the main disorder target groups:
- Pain connected with the musculoskeletal system, for instance fibromyalgia or chronic low back pain
- Mental disorders (mainly depression and anxiety disorders) with or without obvious social causal factors
- Other, for instance fear of becoming ill
The survey is, however, not restricted to any specific diagnostic groups, and may thus be just as useful for a diabetic who is striving to reduce his blood sugar content as for a cancer patient with many different problems, or for patients with a ‘fat file’ syndrome where treatment options have been exhausted, or if the patient has a suspected hidden agenda.
It is recommended that a doctor–patient relationship should have been established before giving out the survey. Importantly, however, the outcome of using the PPS appears to be more constructive if the doctor–patient relationship has not lasted for too long (<1 year).
3 Introduction of the survey
The GP should inform the patient that he asks him/her to fill in the form because he wants both of them to make headway in their co-operation on the patient's health problem(s). Thus both parties can obtain an overall picture of the patient's complaints, everyday life and perhaps help the patient to see possible connections between health problems and feelings about life in general. Furthermore, it may explore how the patient reacts/copes when faced with complaints and problems and if there is anything he wants to change in this respect. The patient can also write down where he needs help. The two of them are then to go through the survey at the next visit and discuss what can be done. Follow-up visits may have to be arranged.
4 How to perform the PPS-based consultation
At this consultation (normally of twice the normal duration), the completed survey is reviewed and discussed.
Some GPs have found it useful to commence the consultation with reading through the PPS quickly (and of course hereby try to show an appropriate positive body language).
As far as the content of the consultation is concerned, there are different styles that have been shown to function well:
- To use the survey actively as a tool for talks. The patient can be allowed to move across, or give some supplementary information in the course of the talk. The survey is not a ‘sacred cow’.
- To ask the patient what it felt like to fill in the survey; or the doctor may ask the patient to talk about what he or she wants most.
- To comment on any new information, surprises or what is considered important, and use this information later in the conversation. If certain information is left out, this provides an opportunity to ask more questions, from which quite important and perhaps sensitive information may come to light.
- To comment, as a general rule, on what are positive and appreciable resources; recognized connections between life events, life situation and health problems; coping aspects; and, not least, what the patient wants to change or to do in order to improve their health status. Here it may well be appropriate to discuss what kind of help is expected from the doctor.
- To prepare at home, if the patient agrees, a ‘plan of action’ to be discussed in a follow-up consultation (another ‘home lesson’).
5 Interpretation of answers
Regarding health problems/symptoms, on the first page of the PPS, questions (items 1–12) are formulated so that a lot of crosses to the right indicate a large volume of complaints. Both doctor and patient can obtain a visual picture straight away. The same applies to the eight questions on 2 related to the patient's everyday situation.
As regards the nine questions on coping (3), the focus is on two main coping strategies: approaching the problems (first five items) or avoiding them (last four items). The questions are formulated so that the position of the crosses tells something about the patient's mode of coping and to what extent they represent an emotional-, action- or positive cognitive-oriented approach. Such strategies are used commonly. If the patient tended to disagree on these questions, then this could be a sign of poor coping.
The first three avoidance questions cover what is called diverting avoidance, which may function differently depending on the situation and type of personality, but is perhaps in most cases dysfunctional.
The last item refers to avoidance by withdrawal. If the patient indicates such withdrawal, this can be a sign of poor coping. It should be noted whether the patient uses a variety of strategies or uses mainly approach or avoidance strategies. Many ‘unsystematic’ agree/don’t agree answers may indicate that the patient has diffuse and unclear ideas of how he/she copes.
It is suggested that the doctor, when talking to the patient about coping with problems, should try to discover resources, especially examples of dealing with problems actively; and the doctor should try to help the patient to understand and reflect on their own strategies and how they are perceived to function. Is there anything the patient wants to change?
6 How to proceed after the consultation
The doctor is recommended to write a note in the files about what has happened and decisions that have been made, for instance writing a ‘plan of action’, referral to specialists or treatment options such as cognitive therapy, antiphobic training, relaxation therapy or other stress-reducing management modalities; or further talks with their own doctor about how to solve psychosocial problems or lifestyle issues.
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Acknowledgments |
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Thirty-two GPs have contributed with data collection and advice throughout the study. They are all sincerely thanked. This study has been supported by the Norwegian Medical Association's Quality Assurance Fund and by the University of Oslo Network in Clinical Communication.
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References |
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