㈵−22 |
患者教育，医師‐患者関係で留意すべき点は |
論文抄録 |
OBJECTIVE: To determine the feasibility of developing a headache management program and to assess the outcomes of patients referred to the program for treatment of chronic headache. BACKGROUND: Effective headache treatment requires that the patient receives the correct headache diagnosis; that appropriate acute and, if indicated, preventive medications be prescribed; and that the patient receives adequate education, including headache self-management skills. DESIGN/METHODS: A headache management program was established at a northern California staff-model health maintenance organization. Fifty-four patients were enrolled in the program and followed for 6 months. Patients participated in a structured program of group and individual sessions with the program manager. Data collection at baseline and 6 months included the Migraine Disability Assessment (MIDAS), the Short Form-36 Health Survey (SF-36), a patient satisfaction survey, and 2 additional short surveys--one that assessed patient worries about their headaches and another that queried patients on their problems with headache management. RESULTS: All enrolled patients participated in the initial group visit; 74% had at least one additional visit. All but one patient suffered from more than one headache type. Sixty-one percent of patients suffered from migraine headache and 98% from tension-type headache. At baseline, patients were severely disabled, with a mean MIDAS score of 41. At 6 months, MIDAS scores decreased an average of 21.2 points (P <.005). Patients reported 14.5 fewer days with headache over the preceding 3 months (P <.0001) and experienced clinically significant improvements in 6 of the SF-36 subscales. Patients were significantly more satisfied with their headache care (P <.0001), reported less problems with their headache management (P <.0001), and were less worried about their headaches (P <.01). During the intervention, emergency department visits for headache decreased (P <.02). CONCLUSIONS: A headache management program was successfully established. Patients referred to the program experienced significant improvement in headache-related disability and functional health status and reported greater satisfaction with care. Even so, these results were obtained at one site and in a small sample that was not randomized. We currently are conducting a randomized controlled trial to better evaluate the clinical and financial impact of a headache management program for patients with chronic headache. |
文献 PubMed−ID |
PMID: |
エビデンスレベル |
III |
文献タイトル (日本語) |
頭痛治療プログラムは慢性頭痛の転帰を改善する |
目的 |
頭痛治療プログラム 発展の可能性の検証とこのプログラムに参加した慢性頭痛患者の転帰を評価する． |
研究デザイン |
非比較研究 |
研究施設 |
北カリフォルニア職員健康維持組織 (northern California staff-model health maintenance organization) |
研究期間 |
不明 |
対象患者 |
Migraine Disability Assessment (MIDAS) 6 点以上， 18 歳以上で，英語が話せる頭痛患者 |
介入 |
頭痛治療プログラムに参加して治療を行ない 6ヶ月間追跡する |
主要評価項目とそれに用いた 統計学的手法 |
MIDAS ， Short Form-36 Health Survey (SF-36), 患者満足度評価尺度 , 患者の頭痛治療理解度を評価する一連の評価尺度，頭痛心配度評価尺度 |
結果 |
44 名の患者が参加した． 43 名が 2 種類以上の頭痛を有していた． 61% が片頭痛を， 98% が緊張型頭痛を有していた．治療前には高度に障害され MIDAS score の平均は 41 点であった． 6 ヶ月後， MIDAS scores は 21.2 点に改善した ( P < .005). 頭痛日数においても， SF-36 subscales においても有意な改善を認め，また十分な満足度が得られた ( P < .0001) ．頭痛心配度も減少し ( P < .01) ，救急外来受診回数も減少した ( P < .02). |
結論 |
頭痛治療プログラムは有用であった．プログラムに参加した頭痛患者は頭痛に関連した生活障害，身体的健康状態は顕著に改善し，治療に対する高い満足が得られた．この結果は 1 施設における小数例の非ランダム研究におけるものであるが，今後，ランダム研究 (RCT) を行なう予定である． |
備考 |
MeSH Subject Headings Adult California Chronic Disease Data Collection Disability Evaluation *Disease Management Female Headache Disorders/co [Complications] *Headache Disorders/th [Therapy] Human Male Migraine/co [Complications] *Migraine/th [Therapy] *Pain Clinics/og [Organization & Administration] Patient Education/mt [Methods] Patient Satisfaction Program Development Support, Non-U.S. Gov't Treatment Outcome |
作成者 |
根来清 |
論文抄録 |
OBJECTIVE: Review of problems arising from communication difficulties in headache practice. METHODS: Literature review and assessment of practice experience. BACKGROUND: Advances in understanding of the pathophysiology of migraine and the availability of specific acute therapies have given migraine sufferers access to effective treatment and physicians a wide array of therapeutic alternatives. There remains uncertainty about the best drug group for any given patient and about which triptan to use when and in which formulation; about patient preference and satisfaction; about interpretations of pivotal trials and meta-analyses; and about the relevance of large group efficacy and safety data to the individual patient. The clinician may be daunted by the array of triptans with choices of dosage and multiple formulations and will likely learn how to use two or three of them at most, as in depression and hypertension. In the context of the wide array of choices and the complexi!ties of assessing responses and patient preferences, this paper attempts to provide a framework for incorporating the evidence with clinical experience and for communicating these concepts effectively. Benefits, HARMS AND COSTS: None. RESULTS AND CONCLUSION: Even when an appropriate recommendation is determined, therapy may fail unless the doctor patient relationship permits open communication, time for questions and answers and time for instruction on how to use a given medication, and its probable effects. Translating evidence into patient-friendly language is a skill as necessary as that of making the clinical decision itself. Tools are available that can support this effort and aid in creating an environment of "partnership". |
文献 PubMed−ID |
PMID: |
エビデンスレベル |
IV |
文献タイトル (日本語) |
適切な患者に，適切な時点で適切な治療を伝達する :急性期治療 |
目的 |
頭痛臨床における意思伝達の困難さから生じる問題点のレビュー |
研究デザイン |
文献レビュー |
研究施設 |
New England Centre for Headache |
介入 |
なし |
主要評価項目とそれに用いた統計学的手法 |
文献レビューと臨床経験の評価 |
結果 |
たとえ医師が適切な勧告をしても，医師患者関係が不十分でオープンな意志伝達が困難である場合，質問と応答の時間は不十分となり，薬剤をどのように使用するかの説明もうまくいかず，また，得られるおおよその効果についても説明もうまくできず，治療は失敗する可能性がある． |
結論 |
患者になじみのある言葉で医学的事実を患者に正しく伝える技術は，臨床決断 (decision making) を行なうのと同じぐらい，医師にとって必要不可欠な技量である．医師と患者のパートナーシップ環境を作り上げるための手助け，援助となる使用可能ないくつかの手段がある． |
備考 |
MeSH Subject Headings |
作成者 |
根来清 |
論文抄録 |
BACKGROUND: Migraine headaches are often disabling but usually responsive to treatment. Nonetheless, many people with migraine never consult a doctor for headaches. In a sample of the US population, we sought to determine the proportion of active migraineurs who ever consulted a doctor for headache and to identify the headache characteristics and sociodemographic factors associated with consulting. METHOD: A mailed questionnaire survey was sent to 15,000 US households, selected from a panel to be representative of the US population. Of 20,468 eligible respondents ranging in age from 12 to 80 years, 2479 met a case definition for migraine. We mailed a second questionnaire to all migraineurs identified on the first survey and achieved a 69.4% response rate. The second survey assessed headache characteristics, patterns of medical care use, medication use, and method of payment for health care. RESULTS: Sixty-eight percent of female and 57% of male migraineurs reported having ever consulted a doctor for headache. Consultation was more likely with increasing age and in women who ever married. In females, several headache characteristics including pain intensity, number of migraine symptoms, attack duration, and disability were associated with consultation. Of those who never consult, 61% report severe or very severe pain and 67% report severe disability or the need for bed rest with their headaches. CONCLUSION: The results of this survey indicate that a significant proportion of migraine sufferers never consult doctors for their headaches. Given that a large proportion of persons who never consult report high levels of pain and disability, these data suggest that there are opportunities to appropriately increase health care utilization for migraine. Given that 40% of migraineurs who have ever consulted do not report a physician diagnosis of migraine, there is a need to improve headache diagnosis and/or doctor-patient communication about migraine. |
エビデンスレベル |
III |
文献タイトル (日本語) |
片頭痛の受診状況 :アメリカ片頭痛研究の結果から |
目的 |
片頭痛患者のどの程度が医療機関を受診したことがあるかを調べ，医療機関を受診する片頭痛患者の頭痛の特徴と社会的要因を明らかにする． |
研究デザイン |
分析疫学的研究 |
対象患者 |
過去一年に 1回以上の頭痛発作を呈したことがある国際頭痛学会頭痛診断基準に合致した12-80歳の片頭痛患者 |
介入 |
なし |
主要評価項目とそれに用いた統計学的手法 |
片頭痛に関連した診療経験，頭痛の性状，社会的環境，支障度，医師の診断など． |
結果 |
女性片頭痛患者の 68%，男性片頭痛患者の57%が医師の診察を過去に受けたことがあった．高齢者ほど，既婚女性ほど受診率が高かった．女性では，痛みの強さ，片頭痛の随伴症状の多さ，発作の持続，支障度に受診との関連があった．一度も受診経験がない片頭痛患者の61%は高度あるいは極めて高度の痛みを，67%は高度の生活障害あるいは寝込んだ経験があった． |
結論 |
片頭痛患者の多くは頭痛で医師の診察を受けていない．診察経験のない患者の多くが高度の痛みと支障度を経験していることから，片頭痛患者には，より適切なヘルスケアの利用を促進する必要がある．受診歴のある片頭痛患者の 40%が片頭痛の診断を告げられていないことから，頭痛の診断とともに片頭痛に関連した医師?患者関係の改善が必要である． |
備考 |
MeSH Subject Headings |
作成者 |
根来清 |