Changing chronic disease primary care patients' participation through web training : does it make a difference?

Context: Effective communication between physicians and patients can improve health outcomes. We propose that increases in patient participation can lead to better recall of treatment information and reaching treatment goals. Few experimental studies evaluate recall and physiological health outcomes. Objectives: To assess, in patients suffering from chronic diseases and not reaching treatment targets, 1) the impact of a web-intervention promoting patient participation on health outcomes as compared to usual care (study A); 2) Assess what characteristics of physician-patient communication predict patient recall of medication information discussed during the encounter (study B).  Methods: This study used a single blind randomized controlled trial. Patients were randomized into three groups: a) usual care, b) web intervention (e-Learning) and c) combined web intervention and workshop (e-Learning + workshop). Physicians, coders and research assistants extracting data from patients’ charts were blinded to patient allocation. Context: This study was performed in nine urban primary care ambulatory clinics in Ontario between March 2009 and September 2010. Population: Physicians were chosen using a convenience sample and the following eligibility criteria: 1) been in practice at least five years and 2) had a practice orientation including adult chronic disease patients. Patients were considered eligible if they met the following criteria: 1) 40 years or more of age 2) ability to speak English, 3) comfortable using a computer for routine activities such as regular access to the web and e-mail, 4) have a routine follow-up visit scheduled within three to four months of study enrollment, 5) allowed access to their medical records, and 6) not meeting Canadian guidelines for treatment targets and pharmacologically treated for at least one of the following three diseases: hypertension, type II diabetes, and/or dyslipidemia. Study interventions: The web intervention was based on Cegala’s PACE communication approach (Prepare, Ask, Check, Express). Participants in the e-Learning + workshop group benefited from an additional workshop that role-played the same skills. Variables and instruments: Medical encounters were audio-recorded. Physician-patient communication was analyzed with MEDICODE and the Roter Interaction Analysis System. Health outcomes, such as meeting target goals on recommended blood pressure, glycated haemoglobin and lipid profiles were assessed through values extracted from medical records (study A). Patient recall was assessed through answers to a post visit questionnaire completed immediately following the encounter answers compared to audio-recordings (study B). Statistical analyses: Reaching treatment goals was analysed with a modified Poisson regression. The analysis of recall was performed with linear mixed models.  Results: Of the patients meeting eligibility requirements (n=322), 221 participants came to their follow up medical visits. Participants in the e-Learning group had a greater likelihood of meeting their treatment goals compared to usual care (RR=1.52, 95% CI [1.008-2.30]) (study A). For recall analyses, 159 patients were included. Out of six possible medication themes two and a half were broached and less than one was recalled. Discussions with more medication themes, greater dialogue and patient initiative were significant predictors of improved information recall (study B). Conclusion: The results of the two studies provide evidence that patient participation in medical encounters has positive impacts on reaching treatment goals and recall of treatment information. Web-based tools promoting patient participation are important additions in managing chronic disease.

Keyphrases: Communication, Primary care, Chronic disease, Multi-morbidity, Patient education, E-health, Recall, Patient participation, Communication, Randomized controlled trials