Increasing the involvement of elderly patients in healthcare decision making – the IMPROVE study

The idea of giving patients a greater role in decision making about their healthcare is gaining momentum. It is promoted under a number of guises-'patient empowerment’, ‘patient involvement’ and ‘shared decision making’. While GPs generally espouse this philosophy there is evidence we may not always deliver it in practice [1]. Greater involvement of patients in decision making requires us to adapt our traditional somewhat paternalistic and rather controlling consulting style to one that facilitates and allows greater patient involvement. The introduction of a leaflet which prompts the patient to seek more active involvement in the consultation might help. This was the strategy employed by Geest and colleagues in their efforts to improve patient involvement in clinical decision making [2]. They targeted elderly patients as this is a group who have more health problems and who might be inclined to be more passive in consultations. Disappointingly for the authors, they did not manage to demonstrate any significant difference in their outcome measures of patient satisfaction or patient enablement. Indeed, neither did they find any increased perception of being involved from patients in the study.

These findings, though, are not entirely surprising. The before and after design used is an intrinsically weak one. It was sensible and practical to start with this design in a study involving so many countries with such variable research infra-structure, development, and experience. Their intervention was a rather modest one, too, with GPs being visited once for training in the methodology and patients being given, unprompted, a leaflet which invited them to list their consultation agenda and encouraged them to be more active in the consultation. As the authors say, “it may have worked if it had been more intensely applied or if it had been allowed to continue for a longer period of time.” It is now clear that to change to doctor-patient encounter in any significant way requires quite a sophisticated and sustained intervention.

We should not, however, be too despondent about this result. The IMPROVE study is important for several other reasons not specifically related to its findings. The study was a large international effort involving eleven countries, even though data were only sufficient from seven of them. It was grant aided from the EU sixth framework for research. It represents an enormous achievement for academic general practice in Europe and will, hopefully, inspire more such effort and the influx of more EU funding. Although the study has several limitations it also has some major strengths. It involved a large number of GPs in several countries and the feasibility of such international collaboration has now been proven. The study was meticulously conducted with a good deal of piloting and preparatory work put in before the main study. Painful as it must have been for the researchers involved, some countries were, ultimately, excluded from the final report. This was a brave but important demonstration to the wider world that GP research prioritises rigour over inclusivity. The researchers used validated instruments to measure outcomes. These included EUROPEP, a validated patient satisfaction measurement instrument, which was developed collaboratively by researchers in several European countries [3].

This study contains a lot of lessons for GP research in Europe and future international endeavours would to well to heed them. The European Journal of General Practice, will continue to record and publish the burgeoning research effort now occurring in European general practice. We are, indeed, fortunate in having a new publisher, namely Taylor and Francis. We look forward to a long and productive relationship with them. The EJGP is an important element in the establishment of general practice as an academic discipline in Europe. It requires your continued support.