1517
CLINICAL PRACTICE
Economic benefits of teaching patients with chronic obstructive pulmonary disease about their illness
By instructing patients in how to deal with their disease financial demands on health services may be reduced. 100 consecutive patients (aged 48 to 89) admitted to a general medical ward in Denmark with chronic obstructive pulmonary disease (COPD) were allocated randomly to receive either "personalised hospital practice" (PHP), which includes training in aspects of their disease, or standard hospital practice. Changes in of health services per patient from 1 "consumption" year before until 1 year after the intervention admission were evaluated in 82 (PHP group 42, controls 40) patients who completed the intervention phase. Each group contained about the same percentage of asthmatics and smokers. The increase in consumption of health services after intervention was on average Kr15 298 per patient per year less in the PH P group than in the control group (p=0·048, Wilcoxon test). Consumption of general practitioner services was significantly increased in the control group compared with the PHP group (mean [95% Cl] Kr1346 [549 to 2143] vs - 89 [-423 to 245] per patient per year; p=0·001 Wilcoxon test). These differences could not be explained by changes in smoking habits. PHP reduces the consumption of health services by patients with COPD, probably by increasing patients’ knowledge of disease and hence their ability to manage themselves. Introduction To reduce the need for professional help, it makes good teach patients how to deal with their disease. We set out to give patients with chronic obstructive pulmonary disease (COPD) a better quality of life by training them in awareness and treatment of COPD so that they could prevent and treat exacerbations. Our ultimate goal is to reduce the individual’s "consumption" of public health services. In individuals admitted to hospital with COPD, we compared consumption of health services for 1 year before and after intervention in those allocated randomly to sense to
"personalised hospital practice" (PHP), including training or to standard hospital practice.
in their disease,
Patients and methods Patients
aged more than 35 years and admitted consecutively medical ward with COPD during 1988-90, were included in the study. COPD was defmed as pulmonary disease with symptoms of respiratory obstruction or secretions. Patients were excluded if they had had thoracic surgery, or had pulmonary tuberculosis, silicosis, asbestosis, lung cancer, terminal diseases that would prevent them from completing the 1-year follow-up, or severe learning difficulties. Informed consent was obtained from all patients and the study was approved by the local ethics review 100 patients
to our
general
committee. Patients were allocated randomly to the PHP or control groups (50 patients in each group) by "minimisation"l with regard to age, smoking habits, and severity of illness. Patients whose illness became so severe during admission that teaching would have been impossible were excluded from the study irrespective of the regimen to which they had been allocated. The remaining randomised patients participated in the economic evaluation. Patients who were followed up for 1 year after admission made up the clinical-evaluation population.
Treatment Medical
treatment was
the same in each group.
p-agonists were
given if a more than 15 % increase in peak-flow was demonstrated (asthmatics). If necessary, oral steroids were given for some weeks, but inhalation therapy was the preferred form of long-term steroid medication. Some patients with severe asthma were treated with methylxanthines. The PHP and control groups were admitted to separate wards and cared for by separate sets of nurses and doctors. The aim of PHP was to improve patients’ awareness of their illness and their feelings of self-control. During their stay in hospital, each patient in the PHP group was attended by one nurse and one doctor, thus strengthening personal relations between patient and therapists. Training was given by one-to-one teaching and was designed to enable patients to explain or to demonstrate the following: (1) knowledge of disease-ie, production of sputum and bronchoconstriction, the two components of COPD; (2) knowledge of medication-ie, the use and difference between p-agonist and steroid inhalation, and the side effects of medication; (3) knowledge of prophylaxis and precautions at times of exacerbations-ie, when to consult a general practitioner; (4) peakflow technique-ie, correct ADDRESSES: Department of Internal Medicine, Faaborg Hospital, DK-5600 Faaborg, Denmark (L. Tougaard, MD, A. Sorknaes, RN, H. Ellegaard, RN); and Fyns Country Department for Hospital Administration, Odense (T. Krone, CandRerSoc). Correspondence to Dr L Tougaard. *Members of the PASTMA group E. Egelund, RN, H. Ellegaard, R. M. Eriksen, MD, A M. Holm, MD, P. Holm, V. Ibsen, CandRerSoc, T. Krone, CandRerSoc, D Lange, RN, H. Linneman, RN, A. Pedersen, RN, A. Sorknaes, L.
Tougaard, MD.
1518
TABLE I-CLINICAL CHARACTERISTICS AT STUDY ENTRY OF PATIENTS INCLUDED IN ECONOMIC EVALUATION
of the Wright peakflow meter; and (5) inhalation technique-ie, efficient use of the inhalation device. Patients allocated to the traditional hospital practice group use
(controls) were cared for by more than one nurse and doctor. Evaluation
Every patient was assessed clinically and for their level of knowledge of disease at the end of the acute phase of illness, at the time of discharge from hospital, and after 1 year. Severity of respiratory disease and of dyspnoea were assessed subjectively. Arterial blood gas and pulmonary function were tested by standard methods. A patient’s level of knowledge was classified as sufficient if the aims of the training programme had been achieved. The knowledge of patients in the PHP group was also assessed 2 weeks and 3 months after discharge. Health economics The cost of the primary stay in hospital of each patient was estimated from the length of admission and the number of days spent on mechanical ventilation. The time spent by nurses on instructing patients was measured with a stop watch. Consumption of health services was estimated for 1 year before and 1 year after the intervention admission, and included cost of readmission for COPD, days of mechanical ventilation, and cost of general practitioner or specialist consultations. Records of consultations with general practitioners or specialists were obtained from the national health insurance registers. The cost of general practitioner consultations was subdivided into cost in emergency services. The amount of medicine taken by each patient was recorded at the time of discharge from hospital and again at the 1-year follow-up appointment. Costs of medicines were not included in estimates of the consumption of health services. Deaths and readmissions not due to COPD were accounted for in the final calculations. All costs were based on 1990 prices (in Danish Krone [Kr],l-Krl 12).
Results
During the intervention admission, 8 patients in the PHP group dropped out of the study (3 deaths, 5 other causes) as did 10 in the control group (5 deaths, 5 other causes); thus 42 patients in the PHP group and 40 in the control group were included in the economic evaluation. Clinical characteristics TABLE H—LABORATORY ANALYSES OFPATIENTS WITH COPD
I
I
I
FEV,/FVC= forced expiratory volume in 1 s/forced vital capacity. ’p-0 005. Students’s t test.
Fig 1-Change in percentage of patients with sufficient level of knowledge of aspects of COPD. 8 = PH P group, 0 = controls.
of patients included in the economic evaluation did not differ between study groups (tables I and 11). 14 patients in the PHP group (6 deaths, 8 other causes) and 15 in the control group (6 deaths, 9 other causes) were lost from the study during the 1-year follow-up; thus, 28 patients in the PHP group and 25 in the control group completed the
1-year follow-up. At discharge and during follow-up, patients in the PHP and control groups demonstrated equal knowledge of good inhalation technique, but patients in the PHP group generally had better knowledge of all other aspects of their disease (fig 1). In the PHP and control groups after 1 year, dyspnoea had worsened in 50% and 80%, respectively, and improved in 18% and 4% (x2 test, p=006); pulmonary disease had worsened in 14% and 16%, respectively, and improved in 29% and 24% (XZ test, p = 0-79). Mean p02 was significantly decreased after 1 year in the PHP group compared with the control group but changes in pCO2 and lung-function tests did not differ significantly between the groups (table II). The mean (95% CI) length of the intervention admission was about the same in the PHP group (13-4 [10’6-16’2] days per patient) as in the control group (12-7 [10’2-15’2] days
1519
TABLE III-CONSUMPTION OF HEALTH SERVICES BY PATIENTS WITH COPD
Figures are mean (95% CI) Kr/patient per year *p=008,tp=0 001, §p=002, ∥p=0.048 (all Wilcoxon test); ‡p=0.01 (Student’s ttest)
patient), and cost the same amount (Kr28 634 [20 972-36 295] vs Kr26 760 [20 545-32 975] per patient). Patients in the PHP group received 258 (203-302) min training; this was 185 (123-247) min (equivalent to Kr398) more than that given to control patients (Student’s t test, p 0-005). Almost no difference was found between the two groups in mean costs of medicine after 1 year (PHP group Kr4537 [3373-5701] vs controls Kr5647 [4522-6772] per patient per year). In the year before intervention, consumption of health services did not differ significantly between the PHP and control groups (table III). During the follow-up period, however, the increase in consumption of health services was about Krl5 000 per patient per year less in the PHP group than in the control group (table III). 35% of patients in the control group required readmission to hospital compared with 17% in the PHP group (X2 test, p = 0-057), and no patients in the PHP group received respirator treatment compared with 13% of those in the control group (X2 test, p=0-011). Consultation of general practitoners was significantly lower in the PHP group than in the control group (table III). The greatest increase in consumption of health services during the follow-up year was in smokers and in patients aged less than 70 years. In these groups, PHP reduced costs significantly (fig 2). Only 17% of smokers in the PHP group required readmission to hospital, compared with 44% of smokers in the control group (X2 test, p 0-02). There was no significant difference between the PHP and control per
=
=
Fig 2-Mean increase in consumption of health services (Kr/ patient per year) in smokers and non-smokers and patients aged greater than or less than 70 years during the 1-year
follow-up. =PHP group, [] = controls. Wilcoxon
probabilities.
test
used to estimate
groups in the fraction of
patients who stopped smoking during the 1-year follow-up period (34% vs 20%). Discussion
This study shows that teaching patients with COPD about their disease reduces consumption of health services. This reduction is due to fewer consultations of general practitioners and fewer readmissions to hospital by patients who have had PHP. A controlled study of 38 paients with adult asthma showed that training in asthma reduced readmissions to hospital ;2 however, our study is, as far as we are aware, the first economic evaluation of PHP in patients admitted to hospital with COPD. The Danish national health service is publicly financed, therefore consumption of health services is not influenced by a patient’s financial means. Teaching patients with COPD about their disease will probably influence patterns of consumption differently in other health systems. Although many patients in the study did not attend the 1-year follow-up appointment, data about their consumption of health services could be obtained from hospital and national health insurance records. Most patients received retirement pensions and help in their homes before intervention; therefore, costs of changed working capacity and domestic help were not evaluated. Lower consumption of health services by the PHP patients could not be explained by clinical differences between the two groups. Indeed, longer duration of pulmonary symptoms and greater use of general practice emergency services by the PHP group before intervention suggest that these patients were initially sicker than controls. Although most patients had asthmatic symptoms, they represented a broad range of patients with COPD. The positive effect of PHP was found despite this lack of homogeneity in patients’ illnesses, which is typical of a general medical ward with many elderly patients. Medical treatment and the criteria for starting respirator treatment were the same in PHP and control patients, and seriously ill patients were always assessed by an experienced doctor who was not involved in the study. Thus, we believe that differences between the two groups do not reflect biased criteria for treatment. Training in disease produced an especially striking reduction in consumption of health services among both smokers and patients less than 70 years old. Stopping smoking may have had beneficial effects on health but no significant changes were found. Patients’ level of knowledge of disease at the time of discharge from hospital was found to be a good indicator of lower consumption of health services during the follow-up year. We could not test the effect of PHP on the individual, but it is our belief that the combination of skilled medical
1520
training and PHP enabled patients to treat themselves while using fewer resources. Patients in the PHP group were more enthusiastic, more confident, and had greater self-awareness than controls. Although patients in the PHP group were instructed to consult their general practitioner and admit themselves to hospital at an early stage of their exacerbation they reduced their demands on health services. This may be due to patients in the PHP group feeling in less need of help from others. This study shows that PHP can reduce consumption of health services after discharge from hospital. Since
Effect of
introducing PHP in our department we have also found a considerable shortening of the average length of in-hospital stay.33 REFERENCES 1. Tave DR. Minimization: a new method of assigning patients treatment and control groups. Clin Pharmacol Ther 1974; 15: 443-49. 2. Ringsberg KC, Wiklund I, Wilhelmsen L. Education of adult patients at an "asthma school": effects on quality of life, knowledge and need for nursing. Eur Respir J 1990; 3: 33-37. 3. Tougaard L, Anderson KD, Jung E, et al. Stuegang afskaffet. Ugeskr
Laeger 1991;153:1306-09.
presentation of partogram information on obstetric decision-making
The way in which medical information is presented may affect doctors’ decision-making. We have assessed whether changing the appearance of the same information on the partogram affects clinical decisions during labour. Sixteen junior obstetricians were asked about how they would manage six hypothetical cases of difficult labour. Information was given by partogram, in which we varied either the relative scales of the x and y axes or whether the latent phase of labour had been included. Doctors were more likely to intervene and to intervene more actively if the progress of labour curve appeared flat and if the latent phase was included. The shape and point of origin of the partogram probably influence intervention rates in practice and may partly explain the low rates of caesarean section in some hospitals.
Introduction
Graphic designers know that the way information is presented influences audience behaviour.1 For example, to exaggerate, say, a rising crime rate, a journalist merely has to choose a scale on a graph so that the crime rate curve rises more steeply, or the lower values from one axis can be omitted so that the percentage increase seems greater. Similar factors probably affect the interpretation of medical data and influence doctors’ decisions. Obstetricians have to decide whether and when to intervene during labour-ie, to accelerate it with oxytocics or by rupture of the membranes, or to deliver the baby by forceps or caesarean section. Opinions differ about the indications for these interventions, and obstetricians may disagree both among themselves and with their own earlier decisions.2 The increasing rate of intervention in labour both in the UK and in the USA is worrying, so any relevant factors that might influence whether an obstetrician intervenes during labour should be investigated. Labour progress is usually monitored with a partogram, which is a graph of cervical dilatation against time.33 Partograms vary with respect to the relation between the vertical scale (y axis) used for cervical dilatation and the horizontal scale (x axis) representing elapsed time in labour or since admission. Obstetric units also have different policies about when a partogram should be started. Possible
differences between partograms are shown in fig 1 in which that used in the National Maternity Hospital in Dublin (which has a very low caesarean rate) with a time (hours)-todilatation (cm) ratio (x/y) of 1/1is compared with two others (from anonymous hospitals) with 2/1 and 2-66/1 ratios. We set out to see whether either the gradient of the curve or inclusion of the latent phase on the partogram influenced doctors’ decision-making. We decided to test the hypothesis that doctors would be more likely to intervene when the scale of the partogram led to a flattened cervical dilatation curve or when the latent phase of labour was drawn on the partogram, since a flat partogram and a long latent phase would tend to point to impending labour or difficulty and the need for intervention.
Methods A convenience sample of sixteen junior obstetricians were asked how they would each manage a series of six hypothetical labours. In each case, labour progress was slow or there was some other factor (such as borderline evidence of fetal distress) that might prompt intervention, especially if labour was progressing slowly. All cases were selected so that difficult decisions were needed. Each doctor was presented with the details of each case twice in random order two months apart as follows:
before first interview.
They were not told about our hypothesis nor that they would see the same information presented in two different ways. In the two presentations of each case, the factual information including the cardiotocograph was the same but the format of presentation of the cervical dilatation information was varied. In the first three cases partograms with a steep format (x to y ratio of 1/1) and a shallow format (1-5/1) were used (fig 2a and 2b). In the last three cases partograms with and without an eight-hour latent phase of labour
University Department of Obstetrics and Gynaecology, St James’ Hospital, Leeds, UK (R. S. V. Cartmill, MRCOG, J. G. Thornton, MD). Correspondence to Mr J. G. Thornton, Institute of Epidemiology and Health Services Research, Leeds University, 34 Hyde Terrace, Leeds LS2 9LN, UK.
ADDRESSES:
CLINICAL PRACTICE
Economic benefits of teaching patients with chronic obstructive pulmonary disease about their illness
By instructing patients in how to deal with their disease financial demands on health services may be reduced. 100 consecutive patients (aged 48 to 89) admitted to a general medical ward in Denmark with chronic obstructive pulmonary disease (COPD) were allocated randomly to receive either "personalised hospital practice" (PHP), which includes training in aspects of their disease, or standard hospital practice. Changes in of health services per patient from 1 "consumption" year before until 1 year after the intervention admission were evaluated in 82 (PHP group 42, controls 40) patients who completed the intervention phase. Each group contained about the same percentage of asthmatics and smokers. The increase in consumption of health services after intervention was on average Kr15 298 per patient per year less in the PH P group than in the control group (p=0·048, Wilcoxon test). Consumption of general practitioner services was significantly increased in the control group compared with the PHP group (mean [95% Cl] Kr1346 [549 to 2143] vs - 89 [-423 to 245] per patient per year; p=0·001 Wilcoxon test). These differences could not be explained by changes in smoking habits. PHP reduces the consumption of health services by patients with COPD, probably by increasing patients’ knowledge of disease and hence their ability to manage themselves. Introduction To reduce the need for professional help, it makes good teach patients how to deal with their disease. We set out to give patients with chronic obstructive pulmonary disease (COPD) a better quality of life by training them in awareness and treatment of COPD so that they could prevent and treat exacerbations. Our ultimate goal is to reduce the individual’s "consumption" of public health services. In individuals admitted to hospital with COPD, we compared consumption of health services for 1 year before and after intervention in those allocated randomly to sense to
"personalised hospital practice" (PHP), including training or to standard hospital practice.
in their disease,
Patients and methods Patients
aged more than 35 years and admitted consecutively medical ward with COPD during 1988-90, were included in the study. COPD was defmed as pulmonary disease with symptoms of respiratory obstruction or secretions. Patients were excluded if they had had thoracic surgery, or had pulmonary tuberculosis, silicosis, asbestosis, lung cancer, terminal diseases that would prevent them from completing the 1-year follow-up, or severe learning difficulties. Informed consent was obtained from all patients and the study was approved by the local ethics review 100 patients
to our
general
committee. Patients were allocated randomly to the PHP or control groups (50 patients in each group) by "minimisation"l with regard to age, smoking habits, and severity of illness. Patients whose illness became so severe during admission that teaching would have been impossible were excluded from the study irrespective of the regimen to which they had been allocated. The remaining randomised patients participated in the economic evaluation. Patients who were followed up for 1 year after admission made up the clinical-evaluation population.
Treatment Medical
treatment was
the same in each group.
p-agonists were
given if a more than 15 % increase in peak-flow was demonstrated (asthmatics). If necessary, oral steroids were given for some weeks, but inhalation therapy was the preferred form of long-term steroid medication. Some patients with severe asthma were treated with methylxanthines. The PHP and control groups were admitted to separate wards and cared for by separate sets of nurses and doctors. The aim of PHP was to improve patients’ awareness of their illness and their feelings of self-control. During their stay in hospital, each patient in the PHP group was attended by one nurse and one doctor, thus strengthening personal relations between patient and therapists. Training was given by one-to-one teaching and was designed to enable patients to explain or to demonstrate the following: (1) knowledge of disease-ie, production of sputum and bronchoconstriction, the two components of COPD; (2) knowledge of medication-ie, the use and difference between p-agonist and steroid inhalation, and the side effects of medication; (3) knowledge of prophylaxis and precautions at times of exacerbations-ie, when to consult a general practitioner; (4) peakflow technique-ie, correct ADDRESSES: Department of Internal Medicine, Faaborg Hospital, DK-5600 Faaborg, Denmark (L. Tougaard, MD, A. Sorknaes, RN, H. Ellegaard, RN); and Fyns Country Department for Hospital Administration, Odense (T. Krone, CandRerSoc). Correspondence to Dr L Tougaard. *Members of the PASTMA group E. Egelund, RN, H. Ellegaard, R. M. Eriksen, MD, A M. Holm, MD, P. Holm, V. Ibsen, CandRerSoc, T. Krone, CandRerSoc, D Lange, RN, H. Linneman, RN, A. Pedersen, RN, A. Sorknaes, L.
Tougaard, MD.
1518
TABLE I-CLINICAL CHARACTERISTICS AT STUDY ENTRY OF PATIENTS INCLUDED IN ECONOMIC EVALUATION
of the Wright peakflow meter; and (5) inhalation technique-ie, efficient use of the inhalation device. Patients allocated to the traditional hospital practice group use
(controls) were cared for by more than one nurse and doctor. Evaluation
Every patient was assessed clinically and for their level of knowledge of disease at the end of the acute phase of illness, at the time of discharge from hospital, and after 1 year. Severity of respiratory disease and of dyspnoea were assessed subjectively. Arterial blood gas and pulmonary function were tested by standard methods. A patient’s level of knowledge was classified as sufficient if the aims of the training programme had been achieved. The knowledge of patients in the PHP group was also assessed 2 weeks and 3 months after discharge. Health economics The cost of the primary stay in hospital of each patient was estimated from the length of admission and the number of days spent on mechanical ventilation. The time spent by nurses on instructing patients was measured with a stop watch. Consumption of health services was estimated for 1 year before and 1 year after the intervention admission, and included cost of readmission for COPD, days of mechanical ventilation, and cost of general practitioner or specialist consultations. Records of consultations with general practitioners or specialists were obtained from the national health insurance registers. The cost of general practitioner consultations was subdivided into cost in emergency services. The amount of medicine taken by each patient was recorded at the time of discharge from hospital and again at the 1-year follow-up appointment. Costs of medicines were not included in estimates of the consumption of health services. Deaths and readmissions not due to COPD were accounted for in the final calculations. All costs were based on 1990 prices (in Danish Krone [Kr],l-Krl 12).
Results
During the intervention admission, 8 patients in the PHP group dropped out of the study (3 deaths, 5 other causes) as did 10 in the control group (5 deaths, 5 other causes); thus 42 patients in the PHP group and 40 in the control group were included in the economic evaluation. Clinical characteristics TABLE H—LABORATORY ANALYSES OFPATIENTS WITH COPD
I
I
I
FEV,/FVC= forced expiratory volume in 1 s/forced vital capacity. ’p-0 005. Students’s t test.
Fig 1-Change in percentage of patients with sufficient level of knowledge of aspects of COPD. 8 = PH P group, 0 = controls.
of patients included in the economic evaluation did not differ between study groups (tables I and 11). 14 patients in the PHP group (6 deaths, 8 other causes) and 15 in the control group (6 deaths, 9 other causes) were lost from the study during the 1-year follow-up; thus, 28 patients in the PHP group and 25 in the control group completed the
1-year follow-up. At discharge and during follow-up, patients in the PHP and control groups demonstrated equal knowledge of good inhalation technique, but patients in the PHP group generally had better knowledge of all other aspects of their disease (fig 1). In the PHP and control groups after 1 year, dyspnoea had worsened in 50% and 80%, respectively, and improved in 18% and 4% (x2 test, p=006); pulmonary disease had worsened in 14% and 16%, respectively, and improved in 29% and 24% (XZ test, p = 0-79). Mean p02 was significantly decreased after 1 year in the PHP group compared with the control group but changes in pCO2 and lung-function tests did not differ significantly between the groups (table II). The mean (95% CI) length of the intervention admission was about the same in the PHP group (13-4 [10’6-16’2] days per patient) as in the control group (12-7 [10’2-15’2] days
1519
TABLE III-CONSUMPTION OF HEALTH SERVICES BY PATIENTS WITH COPD
Figures are mean (95% CI) Kr/patient per year *p=008,tp=0 001, §p=002, ∥p=0.048 (all Wilcoxon test); ‡p=0.01 (Student’s ttest)
patient), and cost the same amount (Kr28 634 [20 972-36 295] vs Kr26 760 [20 545-32 975] per patient). Patients in the PHP group received 258 (203-302) min training; this was 185 (123-247) min (equivalent to Kr398) more than that given to control patients (Student’s t test, p 0-005). Almost no difference was found between the two groups in mean costs of medicine after 1 year (PHP group Kr4537 [3373-5701] vs controls Kr5647 [4522-6772] per patient per year). In the year before intervention, consumption of health services did not differ significantly between the PHP and control groups (table III). During the follow-up period, however, the increase in consumption of health services was about Krl5 000 per patient per year less in the PHP group than in the control group (table III). 35% of patients in the control group required readmission to hospital compared with 17% in the PHP group (X2 test, p = 0-057), and no patients in the PHP group received respirator treatment compared with 13% of those in the control group (X2 test, p=0-011). Consultation of general practitoners was significantly lower in the PHP group than in the control group (table III). The greatest increase in consumption of health services during the follow-up year was in smokers and in patients aged less than 70 years. In these groups, PHP reduced costs significantly (fig 2). Only 17% of smokers in the PHP group required readmission to hospital, compared with 44% of smokers in the control group (X2 test, p 0-02). There was no significant difference between the PHP and control per
=
=
Fig 2-Mean increase in consumption of health services (Kr/ patient per year) in smokers and non-smokers and patients aged greater than or less than 70 years during the 1-year
follow-up. =PHP group, [] = controls. Wilcoxon
probabilities.
test
used to estimate
groups in the fraction of
patients who stopped smoking during the 1-year follow-up period (34% vs 20%). Discussion
This study shows that teaching patients with COPD about their disease reduces consumption of health services. This reduction is due to fewer consultations of general practitioners and fewer readmissions to hospital by patients who have had PHP. A controlled study of 38 paients with adult asthma showed that training in asthma reduced readmissions to hospital ;2 however, our study is, as far as we are aware, the first economic evaluation of PHP in patients admitted to hospital with COPD. The Danish national health service is publicly financed, therefore consumption of health services is not influenced by a patient’s financial means. Teaching patients with COPD about their disease will probably influence patterns of consumption differently in other health systems. Although many patients in the study did not attend the 1-year follow-up appointment, data about their consumption of health services could be obtained from hospital and national health insurance records. Most patients received retirement pensions and help in their homes before intervention; therefore, costs of changed working capacity and domestic help were not evaluated. Lower consumption of health services by the PHP patients could not be explained by clinical differences between the two groups. Indeed, longer duration of pulmonary symptoms and greater use of general practice emergency services by the PHP group before intervention suggest that these patients were initially sicker than controls. Although most patients had asthmatic symptoms, they represented a broad range of patients with COPD. The positive effect of PHP was found despite this lack of homogeneity in patients’ illnesses, which is typical of a general medical ward with many elderly patients. Medical treatment and the criteria for starting respirator treatment were the same in PHP and control patients, and seriously ill patients were always assessed by an experienced doctor who was not involved in the study. Thus, we believe that differences between the two groups do not reflect biased criteria for treatment. Training in disease produced an especially striking reduction in consumption of health services among both smokers and patients less than 70 years old. Stopping smoking may have had beneficial effects on health but no significant changes were found. Patients’ level of knowledge of disease at the time of discharge from hospital was found to be a good indicator of lower consumption of health services during the follow-up year. We could not test the effect of PHP on the individual, but it is our belief that the combination of skilled medical
1520
training and PHP enabled patients to treat themselves while using fewer resources. Patients in the PHP group were more enthusiastic, more confident, and had greater self-awareness than controls. Although patients in the PHP group were instructed to consult their general practitioner and admit themselves to hospital at an early stage of their exacerbation they reduced their demands on health services. This may be due to patients in the PHP group feeling in less need of help from others. This study shows that PHP can reduce consumption of health services after discharge from hospital. Since
Effect of
introducing PHP in our department we have also found a considerable shortening of the average length of in-hospital stay.33 REFERENCES 1. Tave DR. Minimization: a new method of assigning patients treatment and control groups. Clin Pharmacol Ther 1974; 15: 443-49. 2. Ringsberg KC, Wiklund I, Wilhelmsen L. Education of adult patients at an "asthma school": effects on quality of life, knowledge and need for nursing. Eur Respir J 1990; 3: 33-37. 3. Tougaard L, Anderson KD, Jung E, et al. Stuegang afskaffet. Ugeskr
Laeger 1991;153:1306-09.
presentation of partogram information on obstetric decision-making
The way in which medical information is presented may affect doctors’ decision-making. We have assessed whether changing the appearance of the same information on the partogram affects clinical decisions during labour. Sixteen junior obstetricians were asked about how they would manage six hypothetical cases of difficult labour. Information was given by partogram, in which we varied either the relative scales of the x and y axes or whether the latent phase of labour had been included. Doctors were more likely to intervene and to intervene more actively if the progress of labour curve appeared flat and if the latent phase was included. The shape and point of origin of the partogram probably influence intervention rates in practice and may partly explain the low rates of caesarean section in some hospitals.
Introduction
Graphic designers know that the way information is presented influences audience behaviour.1 For example, to exaggerate, say, a rising crime rate, a journalist merely has to choose a scale on a graph so that the crime rate curve rises more steeply, or the lower values from one axis can be omitted so that the percentage increase seems greater. Similar factors probably affect the interpretation of medical data and influence doctors’ decisions. Obstetricians have to decide whether and when to intervene during labour-ie, to accelerate it with oxytocics or by rupture of the membranes, or to deliver the baby by forceps or caesarean section. Opinions differ about the indications for these interventions, and obstetricians may disagree both among themselves and with their own earlier decisions.2 The increasing rate of intervention in labour both in the UK and in the USA is worrying, so any relevant factors that might influence whether an obstetrician intervenes during labour should be investigated. Labour progress is usually monitored with a partogram, which is a graph of cervical dilatation against time.33 Partograms vary with respect to the relation between the vertical scale (y axis) used for cervical dilatation and the horizontal scale (x axis) representing elapsed time in labour or since admission. Obstetric units also have different policies about when a partogram should be started. Possible
differences between partograms are shown in fig 1 in which that used in the National Maternity Hospital in Dublin (which has a very low caesarean rate) with a time (hours)-todilatation (cm) ratio (x/y) of 1/1is compared with two others (from anonymous hospitals) with 2/1 and 2-66/1 ratios. We set out to see whether either the gradient of the curve or inclusion of the latent phase on the partogram influenced doctors’ decision-making. We decided to test the hypothesis that doctors would be more likely to intervene when the scale of the partogram led to a flattened cervical dilatation curve or when the latent phase of labour was drawn on the partogram, since a flat partogram and a long latent phase would tend to point to impending labour or difficulty and the need for intervention.
Methods A convenience sample of sixteen junior obstetricians were asked how they would each manage a series of six hypothetical labours. In each case, labour progress was slow or there was some other factor (such as borderline evidence of fetal distress) that might prompt intervention, especially if labour was progressing slowly. All cases were selected so that difficult decisions were needed. Each doctor was presented with the details of each case twice in random order two months apart as follows:
before first interview.
They were not told about our hypothesis nor that they would see the same information presented in two different ways. In the two presentations of each case, the factual information including the cardiotocograph was the same but the format of presentation of the cervical dilatation information was varied. In the first three cases partograms with a steep format (x to y ratio of 1/1) and a shallow format (1-5/1) were used (fig 2a and 2b). In the last three cases partograms with and without an eight-hour latent phase of labour
University Department of Obstetrics and Gynaecology, St James’ Hospital, Leeds, UK (R. S. V. Cartmill, MRCOG, J. G. Thornton, MD). Correspondence to Mr J. G. Thornton, Institute of Epidemiology and Health Services Research, Leeds University, 34 Hyde Terrace, Leeds LS2 9LN, UK.
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