Psychological approaches to a patient-centered cardiology. Somatic symptom burden, illness perceptions and supportive care needs in patients with cardiac diseases

Patient-centered care is a new treatment approach for chronic conditions. Based on patients’ personal experience with a condition it aims at empowering patients to become active partners in health care. The positive effect of patient-centered care on health outcomes is well-established for several chronic diseases. In 2012 the American College of Cardiology highlighted the role of patient-centered care and strongly emphasized the clinical implementation of a patient-centered cardiology. Although psychological approaches could enhance the outcomes of a patient-centered cardiology they have not been considered yet. Psychological approaches could capture patients’ perception of symptoms, cardiac diseases and treatment needs, and thus, provide a basis for an effective patient-centered cardiology. The present dissertation is based on three studies that investigated the perspective of patients with cardiac diseases on symptom, disease, and treatment level. The first study addresses patients’ perceived symptom level and investigates subjective somatic symptom burden in patients with coronary heart disease. Results indicate that somatic symptoms are frequent and burdensome with a wide spectrum. Rather than cardiac symptoms, pain and energy loss are most frequent. Over and above cardiac markers, psychological factors (i.e. depression and anxiety) predict somatic symptom burden. Moreover, as the overall somatic symptom severity largely contributes to a decreased quality of life, the wide spectrum of somatic symptoms (i.e. energy loss) needs to be targeted in clinical routine. The second study focuses patient’s perceived disease level and examines whether patients at risk for decline in health status can be identified before heart valve replacement surgery by profiling their illness perceptions. Results show that patients can be grouped according to the nature and value of illness perception profiles (stable vs. changing; negative vs. positive). Moreover, pre-operative illness perception profiles predict cardiac health status and quality of life one year after heart valve replacement surgery. As follows, patients at risk for decline in health status could be detected before surgery by assessing their illness perception profiles. The third study targets patients’ perceived treatment level. To date, it is the first investigation of supportive care needs in patients with cardiovascular disorders. Results indicate that needs concerning health information and psychological support are frequent unmet supportive care needs. Rather than the cardiac risk profile, patients’ experience with the treatment (i.e. emergency referral, surgery, medication), mood state (i.e. depression and anxiety), and quality of life are associated with supportive care needs. Interestingly, patients who have been in psychotherapy report fewer unmet health needs. An effective treatment of cardiovascular disorders should not only be based on patients’ cardiac risk profile but should also incorporate the subjective need for help on health information and psychological issues. Based on the results of three studies, the present dissertation highlights the importance of incorporating psychological approaches into a patient-centered cardiology. In terms of clinical applications, assessing patients’ perspective on symptom, disease and treatment level with psychological questionnaires could enhance a patient-centered cardiology. Patient-centered cardiology is defined as an evidence-based model of practice. As follows, further research is needed to validate the implementation of the investigated psychological approaches in clinical practice

Health Care for Persistent Somatic Symptoms Across Europe: A Qualitative Evaluation of the EURONET-SOMA Expert Discussion

Background: Persistent somatic symptoms (PSS), referred to as somatoform disorders and lately somatic symptom disorders, are frequent but often remain under-recognized and under-treated. Although European guidelines overlap, presumably, there is large diversity in their practical use and in the actual health care situation. The aim of this qualitative evaluation was to compare health care for PSS across 9 European countries, to illustrate commonalities and differences, and to discuss challenges for a pan-European research agenda.Methods: A case vignette fulfilling ICD-10 criteria of undifferentiated somatization disorder was presented to 24 experts from 9 European countries, who completed a semi-structured assessment regarding the routine management including diagnostic procedures, treatment recommendations, and country-specific health care aspects. A qualitative evaluation was conducted using the video-transcripts of the presentations. Results were validated by additional expert interviews.Results: Across all countries, primary care physicians serve as the gate keeper for further diagnostic and treatment procedures. Apart from this commonality, there is a large variability in health care routines. Experts concluded that individuals with PSS appear to be a non-identified patient group within many European health care systems. To overcome the gap between evidence-based guidelines and clinical reality needs, three key challenges were identified: (1) Defining a clinically useful, acceptable, and non-stigmatizing diagnostic term, (2) implementing guideline recommendations into routine care, (3) developing effective dissemination strategies.Conclusions: The results advocate for more research on the actual European health care situation. A systematic European research agenda with unified goals and interdisciplinary collaboration that integrates all stakeholders could answer this challenge

Real-World Clinical Practice of Intensified Chemotherapies for Metastatic Pancreatic Cancer: Results from a Pan-European Questionnaire Study

Introduction: Recently, FOLFIRINOX and gemcitabine + nab-paclitaxel have been introduced as a novel intensified chemotherapy regimen for patients with metastasized pancreatic cancer. This study aims to analyze the real-world clinical practice with FOLFIRINOX and gemcitabine + nab-paclitaxel across Europe. Methods: Invitations to participate in an anonymous web-based questionnaire were sent via e-mail to 5,420 doctors in 19 European countries through the network of national gastroenterological, oncological, surgical and pancreatic societies as well as the European Pancreatic Club. The questionnaire consisted of 20 questions, 14 regarding the use of intensified chemotherapy, 4 regarding demographics of the participants, and 1 to verify the active involvement in the management of metastatic pancreatic cancer. Results: Two hundred and thirteen responses were received and 153 entries were valid for analysis. Of those, 63.4% came from an academic institution, 51% were oncologists, and 52% treated more than 25 cases per year. A majority of responses (71%) were from Italy (40%), Germany (23%), and Spain (8%). As first-line therapy, 11% used gemcitabine +/- erlotinib, 42% used FOLFIRINOX, and 47% used gemcitabine + nab-paclitaxel. Of the intensified regimens, both were applied to equal parts, but the likelihood of protocol deviation was higher when using FOLFIRINOX (p < 0.01). FOLFIRINOX was considered more toxic than gemcitabine + nab-paclitaxel (neutropenia 88 vs. 68%; polyneuropathy 42 vs. 41%; rapid deterioration 42 vs. 31%). FOLFIRINOX was rated to achieve longer survival with an acceptable quality of life (52 vs. 44%). Moreover, 57% of participants thought that gemcitabine + nab-paclitaxel should be the backbone for further clinical trials in pancreatic cancer. Conclusion: Intensified chemotherapy is widely used in pancreatic cancer patients in Europe following its recent clinical approval. Interestingly, nab-paclitaxel and FOLFIRINOX were used at comparable frequency although the latter had to be de-escalated more often

Nurses’ experiences of a screening and associated psychosomatic consultation service for mental comorbidities in somatic care inpatients – a qualitative study

BackgroundScreening for mental comorbidities and related liaison service can reduce hospital length of stay in somatic hospital care. To develop, test and sustain such health care services, stakeholder feedback is required. One of the most important stakeholders in general hospital care and health care processes are nurses.AimThe aim of this study is to explore nurses’ experiencess on standardized nurse-led screening for mental comorbidities and associated psychosomatic consultation service in routine somatic inpatient care.MethodSemi-structured qualitative interviews were conducted with 18 nurses that were involved in a nurse-led screening service for mental comorbidities on internal medicine or dermatological wards. Data were analyzed using thematic analysis.ResultsEight thematic groups were developed. On the one hand, participants reported benefits of screening: mental health education, general mental health awareness, holistic treatment approach, opportunity to build rapport with patients and reduction in workload. On the other hand, possible psychological effects of the intervention, reasons why patients may not want to be referred and application requirements to facilitate delivery were identified. None of the nurses opposed screening and associated psychosomatic consultation service.ConclusionAll nurses endorsed the screening intervention and considered it meaningful. Nurses particularly emphasized the potential for holistic patient care and nurses’ improved skills and competencies, but partly critizised current application requirements.Relevance to clinical practiceThis study adds on existent evidence on nurse-led screening for mental comorbidities and associated psychosomatic consultation service by emphasizing its potential to improve both patient care as well as nurses’ perceived self-efficacy and job satisfaction. To take full advantage of this potential, however, usability improvements, regular supervision, and ongoing training for nurses need to be considered

Herkunftsvergleich Karpfen: Vergleich der Eignung verschiedener Gebrauchskarpfenbestände (Cyprinus carpio L.) zur Teichaufzucht unter Verwendung des „Communal testings“ und Zuordnung von Herkünften über Mikrosatellitenmarkeranalysen

Die Leistung sächsischer Teichkarpfen wurde mit genetisch und räumlich weit entfernten europäischen Zuchtlinien verglichen. Zwischen den ausgewählten Herkünften des Karpfens konnten deutliche Leistungsunterschiede festgestellt werden. Es gab jedoch keine Herkunft, die in allen geprüften Belangen den anderen deutlich überlegen war. Herausragend positive Ergebnisse hinsichtlich ihrer Eignung für die Teichaufzucht erreichten Schuppenkarpfen einer tschechischen Herkunft. Im Ergebnis der Untersuchungen werden Empfehlungen für die praktische Zuchtarbeit in Karpfenvermehrungsbetrieben gegeben

Needs of multimorbid heart failure patients and their carers: a qualitative interview study and the creation of personas as a basis for a blended collaborative care intervention

IntroductionInvolving patients and carers in the development of blended collaborative care (BCC) interventions for multimorbid heart failure (HF) patients is recommended but rarely practised, and research on the patient perspective is scarce. The aim of this study is to investigate patients’ and carers' care-related needs and preferences to better customize a novel international BCC intervention.MethodsA qualitative study design using framework analysis was employed. The study was performed in accordance with the EQUATOR standards for reporting qualitative research (SRQR). Patients aged at least 65 years with HF and at least two other physical diseases as well as their carers completed semistructured interviews in Germany, Italy, and Denmark. Based on these interviews, personas (prototype profiles of patients and carers) were created.ResultsData from interviews with 25 patients and 17 carers were analysed. Initially, seven country-specific personas were identified, which were iteratively narrowed down to a final set of 3 personas: (a) the one who needs and wants support, (b) the one who has accepted their situation with HF and reaches out when necessary, and (c) the one who feels neglected by the health care system. Carers identifying with the last persona showed high levels of psychological stress and a high need for support.DiscussionThis is the first international qualitative study on patients' and carers' needs regarding a BCC intervention using the creation of personas. Across three European countries, data from interviews were used to develop three contrasting personas. Instead of providing “one size fits all” interventions, the results indicate that BCC interventions should offer different approaches based on the needs of individual patients and carers. The personas will serve as a basis for the development of a novel BCC intervention as part of the EU project ESCAPE (Evaluation of a patient-centred biopSychosocial blended collaborative CAre Pathway for the treatment of multimorbid Elderly patients)

Integrated care for older multimorbid heart failure patients:protocol for the ESCAPE randomized trial and cohort study

ESCAPE Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients. Therapeutic Area Healthcare interventions for the management of older patients with multiple morbidities. Aims Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients. Hypothesis A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months. Methods Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan—customized to the patients' individual needs and preferences—into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months. Conclusions If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond

A European research agenda for somatic symptom disorders, bodily distress disorders, and functional disorders: Results of an estimate-talk-estimate delphi expert study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe