Isaline C. J. M. Eyssen, PhD1,2, Joost Dekker, PhD1–3, Vincent de Groot, MD, PhD1,2, Esther M. J. Steultjens, PhD4,5, Dirk L. Knol, PhD6, Chris H. Polman, MD, PhD7 and Martijn P. M. Steultjens, PhD1,8

From the 1Department of Rehabilitation Medicine, 2EMGO Institute for Health and Care Research, 3Department of Psychiatry, 6Department of Epidemiology and Biostatistics, and 7Department of Neurology, VU University Medical Center, Amsterdam, 4Dutch Association of Occupational Therapy (EN), Utrecht, 5Expertise center Neurorehabilitation, HAN University of applied sciences, Nijmegen, The Netherlands and 8The School of Health, Glasgow Caledonian University, Glasgow, Scotland UK

OBJECTIVE: Despite beneficial effects on communication and process measures, client-centred practice has been shown to result in poor functional outcomes. To examine a potential explanation for poor functional outcomes, this paper aims to assess whether in client-centred therapy more time is spent on diagnostic consultation and less time on actual treatment compared to usual care.

Method: A multicentre cluster randomised controlled trial was performed. Thirteen hospitals and rehabilitation centres, 29 therapists and 269 outpatients with multiple sclerosis participated. Measurements included an inventory of diagnostic and treatment goals, the number of sessions, therapy duration and therapy intensity.

RESULTS: In client-centred therapy, more sessions were used for diagnostic consultation (10.9% points difference, p = 0.030); the time needed to formulate the first treatment goal was longer (11.4 days difference, p = 0.041); there was a tendency towards more goals directed to diagnostic issues (0.69 goals difference, p = 0.056), spending more hours on indirect issues (1.16 h difference, p = 0.051) and towards a longer total therapy period (1.56 months difference, p = 0.058) than in usual care.

CONCLUSION: Client-centred therapy resulted in more intensive diagnostic evaluation and less intensive treatment. This suggests that client-centred therapy should be adjusted towards a more proportional distribution of time devoted to diagnostic evaluation versus actual treatment.

Key words: patient-centred care; rehabilitation; occupational therapy; multiple sclerosis; patient participation; randomised controlled trial.

J Rehabil Med 2014; 46: 00–00

Correspondence address: I.C.J.M. Eyssen, PhD, Department of Rehabilitation Medicine, VU University Medical Center, PO Box 7057, NL-1007 MB Amsterdam, The Netherlands. E-mail: i.eyssen@vumc.nl

Accepted Jan 14, 2014; Epub ahead of print Mar 24, 2014

Introduction

Incorporating a client-centred approach is nowadays widely advocated in healthcare organizations. In client-centred practice, health care professionals do not deal with diseases alone but with people who are concerned about their health (1), with needs that are to be understood (2). The focus is on treating the client as an unique individual, on considering the client’s point of view, and on the participation of the client in the decision-making process and the treatment process (3).

The increasing focus on client-centred practice is driven by the challenges to the health care system to guarantee quality of care, long-term access, and financial sustainability. It is suggested that to meet these challenges, the core value of health should shift from “care for the disease” towards “behaviour and health” (4). This shift implies that the client needs to be empowered and should take more responsibility and control for his/her own health, lifestyle, and therapy. The health professional is expected to act towards a long-term perspective as a coach in self-management interventions (5). Self-management support intends to activate persons to be informed and to be able to manage their situation themselves by assisting and coaching clients and their families (5). Client-centred practice also aims to enable and empower clients to find their own path to improvement (6).

Client-centred practice claims to have a positive effect not only on process outcomes but also on functional outcomes (7–9). Recently we have performed a trial evaluating the efficacy of client-centred practice in clients with multiple sclerosis (MS) in outpatient clinics of hospitals and rehabilitation centres in the Netherlands (10). This trial revealed negative effects of the client-centred intervention on the secondary functional outcomes (i.e. fatigue and health-related quality of life). The process outcomes (i.e. the information-scale of therapy-quality and the client-centredness of the organisation) were in favour of the client-centred intervention (10). Other literature also showed that client-centred practice, despite beneficial effects on communication and on process measures of client-centredness, can result in poor functional outcomes (1, 7).

The aim of the present paper is to establish whether there are differences in processes of care that could have impacted functional outcomes. The hypothesis was that more time is spent on the consultation process and less time on treatment and disease management in client-centred therapy compared to usual care.

Methods

Design and participants

This paper presents the secondary analysis of the data from our trial about the efficacy of client-centred occupational therapy in clients with MS in outpatient clinics of hospitals and rehabilitation centres in the Netherlands (10). A multicentre cluster randomised design was used to minimise contamination bias within the participating centres and to stimulate therapists in the intervention group to support each other to work client-centred. The centres were eligible if they had at least two occupational therapists (OTs) that were regularly providing outpatient care to clients with MS and if they had at least 10 new MS outpatients each year. The OTs were recruited if they were legally registered and if they had no prior post-graduate education in client-centred practice.

Clients with a diagnosis of MS, who were newly referred to the outpatient OT department of the participating centres and who had no OT in the past 6 months preceding inclusion, were eligible. Inclusion criteria were: age > 18 years, limitations in more than one activity of daily life, and a referral for OT. Clients with MS were excluded if they had a single health question, major depression, insufficient control of the Dutch language or did not provide written informed consent. Consecutive eligible clients with MS were included in the trial.

The trial protocol was approved by the local Medical Ethics Committee of the VU University Medical Centre in Amsterdam. All participating centres approved the study before allocation took place.

Randomisation and blinding

Randomisation of institutions was stratified for type of institution (i.e. hospital or rehabilitation centre). The randomisation procedure was based on a random number table and was performed by using a computer-generated sequence with allocation concealment. The random allocation of the institutions was performed before client recruitment and enrolment started. Accordingly, all participating OTs and their clients within the same centre were randomised into the same treatment condition.

The clients themselves were blinded to the treatment allocation. Due to the nature of the intervention, OTs were not blinded: they were instructed not to tell the clients about the allocated intervention.

Interventions

All therapists were familiar with the OT interventions in MS: energy conservation, time management, body mechanics, strategies for task performance and providing adequate assistive devices (11). The experimental intervention comprised client-centred OT according to a structured client-centred process model (the Canadian Practice Process Framework (CPPF)) (12). This client-centred framework describes 8 action points that guide the therapeutic process in a client-centred way (12). The first action point (enter/initiate) represents the first point of contact between the client and therapist where a collaborative decision is made to either engage in or terminate the therapy. At the second action point the therapist and client set the stage by determining how they work together, by clarifying expectations and assumptions and by identifying priority issues and possible goals. Subsequently action point 3 concerns the assessment or evaluation of personal, environmental and occupational factors that underlie the client’s issues. Action point 4 (agree on objectives and plan) involves the therapist and the client to establish goals and agree on the objectives and plan of intervention. The fifth action is to implement the plan with client participation and power-sharing. Action point 6 includes monitoring and modifying by ongoing evaluation to determine if the used strategies are meeting the objectives. In action point 7 the outcome of the plan is evaluated and the attainment of the goals is examined to determine whether goals are met or new goals or plans need to be established. With action point 8, the therapist and the client come to a collaborative decision to either pursue other objectives or conclude the therapeutic relationship (13). The time spent on these action points depends on the client’s and therapist’s situation and therapy process.

Prior to the data collection, all OTs in the experimental group received a two-day course in client-centred practice, treated clients according to the intervention and received a booster session to evaluate initial experiences 4 weeks after the course. They received 4 additional booster sessions during the study’s data collection period. The 7 training sessions consisted of theory, role playing and feedback on audio-visual material of real-time situations. Components that are related to client-centred practice were also addressed in the course, e.g. motivational interviewing, shared decision making, self-management support, patient education, therapeutic modes, enablement skills, communication techniques and culturally sensitive care. The training was not only focused on the interaction and congruence with the client but also with the practice team. The therapists were facilitated in implementing client-centred practice in their practice teams.

The control group of OTs provided usual OT to their clients. They were exempted from mandatory courses in client-centred practice until the end of this project and were invited to take the client-centred-course at no cost after the conclusion of the project.

There is a marked contrast between the experimental and control group. OTs in the experimental group focused on enabling clients to choose, organise and perform activities the clients found useful and meaningful in their environment. In this group, the client-centred process model and a diary with criteria based on the CPPF were provided. OTs in the control group were focused on providing therapy for the client. In the control group, the client-centred framework and tools were not available. Ongoing support by the coordinating researcher was available for both groups. Through visits to the centres and by answering questions the researcher ensured that OTs were motivated to treat the MS-clients as agreed.

Assessments

Data on clients were collected prior to the start of the treatment and comprised demographic information and disease characteristics: gender, age, clinical type of MS, years since diagnosis and the severity of MS (Expanded Disability Status Scale (EDSS) (14).

Before inclusion of the clients, the OTs provided demographic information about gender, age, and years of experience in OT and in MS. From the start to the end of the therapy, the therapist kept a therapy-diary. An inventory was made of the therapy goals (open format), the time the goals were set, the duration of the therapy-sessions (in hours), the intensity of the sessions (number of therapeutic sessions, period and frequency of sessions) and the treatment period (time of the start and the end of the therapy). Two raters independently classified the therapy goals into diagnostic and treatment goals. Two examples of diagnostic goals are 1) inventory of perceived occupational issues and 2) occupational diagnostics of perceived hand function problems. Two examples of treatment goals are 1) independent dressing and 2) maintaining a balance between rest and activity in a day’s schedule. The interrater reliability of the categorization into diagnostic and treatment goals was found to be excellent, Kappa = 0.78 (p < 0.001), 95% confidence interval (CI) (0.73 to 0.83). The percentage of diagnostic sessions was calculated as the number of the direct-contact sessions till the formulation of the first treatment goal divided by the total number of direct contact sessions.

Statistical methods

Analyses were performed according to the intention-to-treat (ITT) principle. Demographic variables and disease characteristics of the participating clients and of the participating therapists were compared between the experimental and control groups to verify prognostic comparability. Two-sided significance tests were used.

Linear mixed models were used to assess the efficacy of client-centred practice, allowing for clustering of clients within therapists and for clustering of therapists within practices. Analyses were adjusted for baseline differences. For the analyses 3 levels of correlations were taken into account: individual patients, therapists and health centres. The health centres and the therapists were random factors, the type of institution (hospital or rehabilitation centre) was a fixed factor. All statistical analyses were conducted according to a prespecified plan using SPSS, version 15.0 (15).

Results

Characteristics

Data from 269 persons (156 in the intervention and 113 clients in the control group) were included in the analyses. Twenty-nine therapists (11 in the intervention and 18 therapists in the control group) of 7 hospitals and 6 rehabilitation centres (6 centres in the intervention and 7 centres in the control group) participated. The dropout rate of the participating clients was similar in the groups (5.1% for the intervention group and 5.3% for the control group). Twelve of the 269 treatment diaries were missing. The inclusion period was 22 months (May 2007–March 2009).

There were significant differences in characteristics between the clients in the intervention group and the control group in terms of age (44 vs 47 years, p = 0.049), type of institution (73% vs 36% hospitals, p = 0.000), academic centre (73% vs 17% academic centres, p = 0.00) and type of MS (39% vs 21% relapsing remitting (RR), 16% vs 14% primary progressive (PP), 12% vs 26% secondary progressive (SP), 6% vs 4% progressive relapsing (PR), p = 0.000). No differences were found for the other characteristics (Table I).

There were no statistically significant differences in the characteristics of the OTs (see Table II).

Frequency and intensity of therapy

Analyses were adjusted for differences in age, institution type, academic-centre and MS-type, by incorporating these variables as fixed factors in the model. The results of the therapy frequency and intensity are presented in Table III.

Client-centred therapy used more sessions for diagnostic consultation than the control group (10.9% points difference, p = 0.030). The time to formulate the first treatment goal was 11.4 days longer in the client-centred therapy (p = 0.041). The results also indicate a trend towards more goals directed towards diagnostic issues within the client-centred therapy than within the usual care (0.69 goals p = 0.056). Other results seem to indicate that less time was spent on actual treatment: the client-centred intervention group spent 1.2 h (p = 0.051) more on indirect issues and the total therapy period took 1.6 months (p = 0.058) longer compared with the usual care period (see Table III).

Discussion