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Background and purpose Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff. Methods A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned. Results Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures. Conclusions In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.

Background: Patients’ perspectives on standardised, multimodal prehabilitation programmes showed barriers to adherence. Further investigation of patients’ ability to prepare is needed. Aim: To investigate what patients with cancer who were due to undergo major abdominal surgery actually were able to do when provided with preoperative, home-based, multimodal recommendations presented in a leaflet. Methods: Patients from the colorectal- or ovarian cancer centre, who were scheduled for major abdominal surgery, received a leaflet with preoperative recommendations. On a daily basis, the patients filled in what they had completed in relation to these recommendations, so that adherence could be investigated. Additionally, face-to-face interviews were conducted to evaluate patients’ experiences of using the leaflet. Malterud’s principles of systematic text condensation were used to analyse the interviews. A convergent design was used to merge the quantitative and qualitative data into a combined interpretation presented in the discussion. Results: A total of 53 patients returned a completed leaflet, and five patients were interviewed. In the combined interpretation, patients’ ability to prepare was presented through four major domains. The domains were adherence and the importance of support, manageable actions leading to change, preparation in a broader perspective and impediments to preparation and to symptom relief. Conclusions: Patients prepared themselves in various ways, which were not limited to recommendations inspired by multimodal prehabilitation. Patients from the ovarian cancer centre increased their weekly exercise during the preoperative period, which indicates that the leaflet not only functioned as a data collection tool, but also motivated and supported the patients in prehabilitation-related actions. Patients’ perspectives on prehabilitation need to be taken into account, when aiming to enhance patient-centredness and adherence.

n this paper, 30 notes written by Swedish dietitians in patient records are analysed, inspired by Critical Linguistics and Critical Discourse Analysis. Focusing on linguistic devices such as agency ...

Rationale, aims and objectives To describe primary care providers' (PCP) attitudes about the impact of a mature, commercial electronic health records (EHR) on clinical practice in settings with experience using the system and to evaluate whether a provider's propensity to adopt new technologies is associated with more favourable perceptions. Method We surveyed PCPs in 11 practices affiliated with three health systems in Texas. Most practices had greater than 5 years of experience with the Epic EHR. The effect of early adopter of technology status was evaluated using logistic regression. Results One hundred forty-six PCPs responded (70%). Most thought the EHR had a positive impact on routine tasks, such as prescription refills (94%), whereas fewer agreed for complex tasks, such as delivery of guideline-concordant care for chronic illnesses (51%). Two-thirds (62%) thought it interfered with eye contact with patients, and 40% reported that it interfered with in-visit communication. Early adopters of technology reported greater positive effects of the EHR, even after adjusting for age, ranging from 2% to 15% higher on satisfaction ratings. Conclusion PCPs practicing in settings with considerable experience using a common commercial EHR identified many positive effects, as well as two key areas for improvement – patient centredness and intelligent decision support. Providers with a propensity to adopt new technologies have more favourable perceptions of the EHR.

Objective A patient-centred approach to discussing life expectancy with cancer patients is recommended in Western countries. However, this approach to eliciting and meeting patient preferences can be challenging for clinicians. The aims of this study were the following: (i) to examine cancer patients' preferences for life expectancy disclosure; and (ii) to explore agreement between cancer patients’ preferences for, and perceived experiences of, life expectancy disclosure. Methods Cancer patients undergoing radiotherapy treatment in metropolitan Australia completed a cross-sectional touchscreen computer survey including optional questions about their life expectancy disclosure preferences and experiences. Results Of the 208 respondents, 178 (86%) indicated that they would prefer their clinician to ask them before discussing life expectancy, and 30 (14%) indicated that they would prefer others (i.e. clinicians, family) to decide whether they were given life expectancy information. Of the 175 respondents who were classified as having a self- determined or other-determined disclosure experience, 105 (60%) reported an experience of life expectancy disclosure that was in accordance with their preferences. Cohen's κ was −0.04 (95% CI, −0.17, 0.08), indicating very poor agreement between patients' preferences for and perceived experiences of life expectancy disclosure (p = 0.74). Conclusions In light of patient-centred prognosis disclosure guidelines, our findings of a majority preference for, and experience of, a self-determined approach to life expectancy disclosure amongst radiation oncology patients are encouraging. However, poor agreement between preferences and experiences highlights that additional effort from clinicians is required in order to achieve a truly patient-centred approach to life expectancy disclosure. Copyright © 2013 John Wiley & Sons, Ltd.

Context With the routinization of evidence-based medicine and of the randomized-controlled trial (RCT), more patients are becoming ‘sites of evidence production’ yet, little is known about how they are recruited as participants; there is some evidence that ‘substantively valid consent’ is difficult to achieve. Objective To explore the views and experiences of nurses recruiting patients to randomized-controlled trials and to examine the extent to which their recruitment practices were patient-centred and patient empowering. Design Semi-structured in-depth interviews; audio recording of recruitment appointments; thematic interactional analysis (drawing on discourse and conversation analysis). Setting and participants Nurses recruiting patients to five publicly funded RCTs and patients consenting to the recording of their recruitment sessions. Main outcome measures The views of recruiting nurses about their recruitment role; the extent to which nurse–patient interactions were patient-centred; the nature of the nurses’ interactional strategies and the nature and extent of patient participation in the discussion. Results The nurses had a keen sense of themselves as clinicians and patient advocates and their perceptions of the trial and its interventions were inextricably linked to those of the patients. However, many of their recruitment practices made it difficult for patients to play an active and informed part in the discussion about trial participation, raising questions over the quality of consent decisions. Conclusion Nurses working in patient recruitment to RCTs need to reconcile two different worlds with different demands and ethics. Evidence production, a central task in evidence-based medicine, poses a challenge to patient-centred practice and more research and relevant training are needed.

OBJECTIVES The development of patient-centred attitudes by health care providers is critical to improving health care quality. A prior study showed that medical students with more patient-centred attitudes scored higher in communication skills as judged by standardised patients (SPs) than students with less patient-centred attitudes. We designed this multicentre study to examine the relationships among students' demographic characteristics, patient-centredness and communication scores on an SP examination. METHODS Early Year 4 medical students at three US schools completed a 12-item survey during an SP examination. Survey items addressed demographics (gender, ethnicity, primary childhood language) and patient-centredness. Factor analysis on the patient-centredness items defined specific patient-centred attitudes. We used multiple regression analysis incorporating demographic characteristics, school and patient-centredness items and examined the effect of these variables on the outcome variable of communication score. RESULTS A total of 351 students took the SP examination and 329 (94%) completed the patient-centredness questionnaire. Responses indicated generally high patient-centredness. Student ethnicity and medical school were significantly associated with communication scores; gender and primary childhood language were not. Two attitudinal factors were identified: patient perspective and impersonal attitude. Multiple regression analysis revealed that school and scores on the impersonal factor were associated with communication scores. The effect size was modest. CONCLUSIONS In a medical student SP examination, modest differences in communication scores based on ethnicity were observed and can be partially explained by student attitudes regarding patient-centredness. Curricular interventions to enhance clinical experiences, teaching and feedback are needed to address key elements of a patient-centred approach to care.

Rationale Current medical student perceptions of patient centredness and the priorities of students for a change in medical care were investigated. Methods We conducted an observational study using questionnaires at the University of Leipzig in Germany. In total, 188 consecutive medical students attending the Department of General Medicine participated in this study. We investigated students’ priorities for an improvement in medical care related to aspects of the patient–doctor relationship and to aspects of organization. Results Receiving more information and undergoing the process of shared decision making was the most important choice; selected by 43.2% as their first priority. The second choice was found to be consultation time (16.2%) which also refers to the patient–doctor relationship. Shorter queues for tests, also considered important for more patient autonomy, were ranked third (14.6%). Medical students participating in this study were least interested in access to specialists, cost of medications and continuity of care. Conclusion For the first time, it is shown that shared decision making, in addition to its many benefits, is not only a patients’, but also a prospective doctors’ top priority. Consequently, medical student training programmes might incorporate shared decision-making training as an important element of patient centredness.

Summary Objective To document differences in provider behaviour between private and public providers in hospital outpatient departments, health centres and clinics in Bangkok, Thailand. Method Analysis of the characteristics of 211 taped consultations with simulated patients. Results Private hospitals and clinics were significantly more responsive. Private clinics but not private hospitals were also significantly more patient-centred. All doctors, but particularly those in private hospitals, prescribed unnecessary and potentially harmful technical investigations and drugs. The direct cost to the patient varied between 1.5 (in public health centres) and 12 (in private hospitals) times the minimum daily wage. The combined cost – to the patient and to the state – in public hospitals and health centres exceeded the cost of consultations in private clinics. Conclusion Market incentives favour responsiveness and a patient-centred approach, but not more appropriate therapeutic decisions. Excessive use of pharmaceuticals is observed among public as well as private providers, but is most pronounced in private hospitals. If patients in Bangkok want to maximize responsiveness and degree of patient-centred care and yet minimize costs and iatrogenesis, they would benefit from avoiding hospitals, both public and private, and, to a lesser extent, specialists. Choosing to use primary facilities, health centres and clinics, particularly when consultations are carried out by general practitioners (GPs), is more beneficial than choosing between public and private providers. Objectif Documenter les differences de comportement chez les praticiens entre secteur prive et public, dans les services de patients ambulants des hopitaux, des centres de sante et des cliniques de Bangkok, Thailande. Methode Analyse des caracteristiques de 211 consultations enregistrees avec des patients simules. Resultats Les hopitaux et cliniques prives repondaient de facon plus significative. Les cliniques privees mais pas les hopitaux prives, avaient une approche plus centree sur le patient. Tous les medecins et en particulier ceux des hopitaux prives, prescrivaient des examinations techniques et des medicaments non necessaires et potentiellement dangereux. Le cout directe pour le patient variait entre 1.5 (dans les centres de sante publique) et 12 (dans les hopitaux prives) fois le revenu minimal journalier. Le cout combine, pour le patient et l’etat, dans les hopitaux publics et les centres de sante depassait le cout des consultations dans les cliniques privees. Conclusion Les incitations du marche favorisent la reponse et l'approche centree sur le patient, mais pas plus de decisions therapeutiques appropriees. L'utilisation excessive de medicaments est observee autant chez les praticiens du secteur public que du secteur prive. Mais, elle est plus accentuee dans les hopitaux prives. Si les patients a Bangkok veulent maximiser la reponse et le degre d'approche centree sur le patient en minimisant les couts et les effets iatrogenes, ils beneficieraient en evitant autant les hopitaux publics que prives et, dans une moindre mesure les specialistes. Choisir l'utilisation des secteurs de soin primaire, des centres de sante et des cliniques - en particulier lorsque les consultations sont menees par un medecin generaliste - est plus benefique que choisir entre dispensateurs publics et prives. Mots cles Reponse, approche centree sur le patient, medication, de patients ambulants, cout, patients simules, prescription, public–prive, protection des consommateurs Objetivo Documentar las diferencias en comportamiento del proveedor entre hospitales privados y publicos en consultas externas, centros de salud y clinicas en Bangkok, Tailandia. Metodo Analisis de las caracteristicas de 211 consultas grabadas con pacientes simulados. Resultados Los hospitales privados y las clinicas tuvieron una respuesta significativamente mejor. Las clinicas privadas, mas no los hospitales privados, tambien tenian una mayor dedicacion al paciente. Todos los medicos, pero particularmente aquellos de hospitales privados, prescribieron medicamentos innecesarios asi como tecnicas o medicamentos bajo investigacion potencialmente peligrosos. El coste directo al paciente variaba entre 1.5 (en centros de salud publicos) y 12 (en hospitales privados) veces la salario diario minimo. El costo combinado – al paciente y al estado – en hospitales publicos y centros de salud excedio el costo de las consultas en clinicas privadas. Conclusion Los incentivos del mercado favorecen el interes y la dedicacion al paciente, pero no la toma de decisiones terapeuticas apropiadas. Se observo un uso excesivo de farmacos tanto el los hospitales publicos como privados, pero de forma mas pronunciada en los hospitales privados. Si los pacientes de Bangkok desean maximizar el interes y el grado de dedicacion en la atencion y ademas minimizar los costos y la iatrogenia, deberian evitar los hospitales, tanto publicos como privados, y en menor extension a los especialistas. Escoger el usar servicios primarios, centros de salud y clinicas, particularmente cuando las consultas son realizadas por medicos generales, es mas benefico que escoger entre proveedores publicos y privados. Palabras clave interes, dedicacion en el cuidado del paciente, medicacion, consultas externas, pacientes simulados, prescripcion, publico-privado, proteccion al consumidor

The definitive version is available at www3.interscience.wiley.com, OBJECTIVE To show that low-cost attitudinal, structural and procedural changes aimed at improving responsiveness to patients have the potential to increase uptake of family planning (FP) even among populations considered reluctant to do so by health personnel. METHODS Intervention study with before–after comparison of contraceptive acceptance, couple-years of protection (CYP) and an `index of contraceptive uptake' (IUC) in rural health centres in Niger. The intervention consists of a package of instructions to actively propose family planning, integrated within curative and under-fives consultations, coupled with measures to increase the health centres' responsiveness to their clients. RESULTS Implementation of the intervention package was followed by marked increases in family planning uptake. CONCLUSION Health services in Niger present an untapped potential for improving family planning through low-cost supply-side measures.