When patients set the goals of therapy…


ResearchBlogging.org

If you’ve been following my blog over the past week or so, you’ll see I’ve been discussion goal setting as part of pain management rehabilitation.  I’ve looked at the things patients may ask for, and the difference between these goals and the goals that clinicians may need to set directly related to the treatment aims. I’ve also looked at the place of goals in life generally, the subskills used to develop and achieve goals, and what happens to people when they can’t achieve the goals they set. I’ve also looked at using Goal Attainment Scaling as a form of outcome measurement. Today I want to look at a study where the effect of patients being involved in goal-setting was measured. Unfortunately, it’s not a study within the chronic pain setting, instead it’s about goal-setting within an inpatient neurological rehabilitation unit. There are clear differences between the model this unit uses compared with most chronic pain management settings – but there are also things we can learn, so here goes!

This study was carried out in The Neurological Rehabilitation Unit at the National Hospital for Neurology and Neurosurgery, London, UK, and involved 200 in-patients, half of whom were involved in ‘normal practice’ and the other half were involved in a programme where increased participation in goal-setting was encouraged.  The patients had a range of neurological conditions including stroke, multiple sclerosis, spinal cord lesions, and a variety of other less common conditions like peripheral nerve disease and central nervous system tumours.

This Unit has a care pathway, which is a set of interlinked goals relating to five main dimensions:

(1) health maintenance,

(2) cognitive functioning,

(3) personal activities of daily living,

(4) participation and

(5) communication.

Method:

All admissions to the unit over an 18 month period were included in the study, except if they had limited ability to communicate in English.  This meant that a total of five patients were excluded.    A ‘repetitive block design’ was used to determine the treatment protocol used, with each block lasting 3 months.

‘At the onset of each phase all staff (physiotherapists, occupational therapists, speech and language therapists, nurses and doctors) working on the neurological rehabilitation unit attended a training session on either the ‘‘usual practice’’ (phase A) or the ‘‘increased participation’’ (phase B) approach which was to be used.’

Measures

Four measures were used: Patients’ beliefs about their involvement rated on a four point scale; Goal relevance was measured as a global rating using a 10 cm visual analogue scale, with the anchors being ‘not at all relevant’ and ‘highly relevant’; each goal was rated on a five point scale from (1) highly relevant to (5) of not relevance whatsoever; patients overall satisfaction was rated on a 10 cm visual analogue scale; the distribution of the goal components was recorded on the five care pathway dimensions , as were the outcome or end status of the goals, and reasons for non-completion of goals (variances) were collected for comparative purposes.  Three functional outcome measures were also taken on admission and discharge (unfortunately, not long-term outcomes) – Functional Independence Measure (FIM),  London Handicap Scale, and  General Health Questionnaire (GHQ-28).

The flowchart shows you the two pathways patients may follow, depending on the month they are admitted.

flowchart

In the experimental group, patients are asked to complete a structured goal-setting workbook before admission, and attend clinical goal-setting meetings.  In the ‘treatment as usual’, goals are set by therapists without direct input from patients.

Results

There were no significant differences between the two groups, except mean age for the ‘‘increased participation’’ group was 4 years younger than ‘treatment as usual’.

Patients correctly identified the origin of goals, depending on the group they were in, and they also identified that their goals were both more relevant, and that they were more satisfied if they were in the experimental group.

Different types of goals were set when participants increased their input to goal-setting.  Notably, people in the experimental group identified a greater number of ‘participation’ goals compared with the ‘treatment as usual’ group.  There were fewer overall goals set in the experimental group, but there was no difference between the number of goals achieved in each group.  Finally, there were no differences in the functional outcome measures between the groups at discharge.

So, what does this mean?

Well, one aspect that did differ between the groups was the degree of satisfaction with treatment – in pain management at least, there is some evidence that expectations that are well-met during treatment are associated with slightly better outcomes. It probably also meant (although this wasn’t directly studied), that adherence to treatment activities during treatment was probably a little higher.  Happier patients probably means happier staff!

It’s interesting that there was no data on the long-term adherence to treatment activities, nor on outcomes between the groups.  I’m inclined to think that people who believe their goals are more relevant to their real life would be more likely to carry on with the treatment activities and therefore the outcomes over time might be more durable.

The main difficulty with generalising from this example to other settings is about the methodology.  This isn’t a blinded RCT.  It would be really difficult to set up a full-blown RCT, but it is a limitation.  There could be systematic differences between the two groups that weren’t readily identifiable – or perhaps there were differences in the way the staff facilitated the processes.

Another difficulty is that this was an in-patient setting, while most pain management in New Zealand, anyway, is within an outpatient setting.  I’m not sure how much this would influence the processes, apart from probably a much closer team working environment in an in-patient setting compared with outpatient.

Patients experiencing chronic pain often report that they feel they are not listened to, and that their concerns are not addressed.  Perhaps by following a systematic process of setting goals, similar to this study, this concern could be addressed.

On the other hand, ACC asks for claimants to determine their ‘functional goals ‘.  As I mentioned when I first posted about goal-setting, lots of patients simply want their pain to be gone, and life to return to normal. It’s not easy to elicit clear goals from patients as many haven’t set goals routinely, and given the lack of direction and sense of disillusionment that many face as part of having chronic pain, perhaps we need to use a structured process to help people establish goal areas, then work through how they might achieve the goals – during both therapy and afterward.

This isn’t the last post from me on goal-setting.  I’m on the hunt to find some good material on which to base a process for developing good goal setting strategies.

What strikes me, though, is the real lack of good clinically-based research demonstrating the effect of goal-setting on patients, and to work out what works, and what doesn’t.  Even some nice descriptive studies would be worthwhile to explore the experiences of patients as they participate in goal-setting!  This is a challenge, folks!  Let’s do it!

R. C Holliday, S. Cano, J. A Freeman, E D. Playford (2007). Should patients participate in clinical decision making? An optimised balance block design controlled study of goal setting in a rehabilitation unit Journal of Neurology, Neurosurgery & Psychiatry, 78 (6), 576-580 DOI: 10.1136/jnnp.2006.102509

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