PRINCE Primary: Integrated GP Care for Persistent Physical Symptoms - a Feasibility & Cluster Randomised Controlled Trial

Persistent Physical Symptoms Clinical Trial

— PRINCE Primary  

Official title:

Persistent Physical Symptoms Reduction Intervention: a Systems Change and Evaluation (PRINCE) - Integrated GP Care for Persistent Physical Symptoms: a Feasibility & Cluster Randomised Controlled Trial

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02444520
• Other study ID #: STR130202 (Primary)
• Status: Completed
• Phase: N/A
• Start date: May 2015
• Est. completion date: January 2018

Study information

• Verified date: August 2018
• Source: King's College London
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

PRINCE primary is cluster randomised waiting list controlled trial to evaluate the feasibility of an integrated approach to care in general practice for adults with persistent physical symptoms (PPS). PPS is defined as physical symptoms with no obvious underlying organic. 240 patients with PPS recruited from 8-12 GP practices in London will be randomised to the integrated care approach plus treatment as usual (TAU) or TAU alone. The integrated GP approach consists of providing GPs with a short cognitive behaviour therapy (CBT) skills training, ongoing supervision, as well as written and audio-visual materials/guidelines. In addition, participants randomised to the intervention group will receive tailored CBT-based self-help materials (i.e. written and audio-visual materials).

Description:

Patients with PPS are often severely functionally impaired and. They consume large amounts of healthcare and welfare benefits. There is an accumulating body of evidence showing that cognitive behavioural interventions can reduce levels of symptoms and improve overall functioning in patients with PPS. CBT has demonstrated both short-term and long-term efficacy with small to medium effect sizes for PPS. Larger treatment effects have been reported for specific PPS syndromes, including non-cardiac chest pain, Irritable Bowel Syndrome (IBS), and Chronic Fatigue Syndrome (CFS).

General practitioners (GPs) play a major role in identifying and managing patients with PPS. A previous randomised parallel group pilot trial investigated the feasibility (i.e. recruitment, retention and acceptability) of implementing a primary care Symptoms Clinic for patients with PPS). The Symptoms Clinic comprised a structured set of consultations delivered by a specially trained GP with a strong interest in PPS. The intervention included exploring potential biological mechanisms underlying the PPS condition, empathetic support, and training patients in symptom-management (i.e. medication or cognitive behavioural techniques). The results indicated that the Symptoms Clinic was acceptable to the majority of patients randomised to the intervention group, and may have the potential to generate clinically significant benefits. However, this pilot study did not assess feasibility parameters referring to GPs' willingness to participate in the study and undergo specialised psychological training. Moreover, the intervention was carried out by only one GP, raising questions about the generalizability of the study.

Managing patients with PPS can be highly challenging in general practice. Although GPs recognise the treatment of PPS as a responsibility of primary care, previous studies show that GPs often feel powerless, frustrated and helpless when encountering these patients. Furthermore, GPs frequently report that factors such as time constraints and the lack of psychological training prevents them from effectively addressing patients' psychosocial needs and developing appropriate doctor-patient communication skills.

The aim of this study is to assess whether it is feasible to conduct an adequately powered future trial to evaluate the efficacy and cost-effectiveness of a CBT-based integrated GP care approach for treating patients with PPS (please refer to arms and interventions for more details).

Recruitment information / eligibility

• Status: Completed
• Enrollment: 161
• Est. completion date: January 2018
• Est. primary completion date: January 2018
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 65 Years

Eligibility

Patients that fit the eligibility criteria will be invited to take part in the study. Patients will be considered eligible for inclusion in this study if they fulfil all of the following criteria:

(i) have a PPS diagnosis (which are medically unexplained) (ii) are greater than or equal to 18 and less than or equal to 65 years old (iii) are registered with a GP practice in South London that has consented to taking part in PRINCE Primary (iv) have had 6 or more consultations in the last year (not necessarily for the same symptom or directly related to PPS (v) have given written informed consent, provided baseline data before randomisation and can speak and read English at a level adequate for participation in the.

Patients will be excluded from the study if the patient has:

(i) active psychosis (ii) drug or alcohol addiction as indicated in the patient's medical notes (iii) current benzodiazepine use exceeding the equivalent of 10mg diazepam per day (iv) had any psychotherapy treatment within the last year (not inclusive of general visits from community psychiatric teams) (v) dissociative seizures (vi) if they are at imminent risk of self-harm, after psychiatric/ psychological assessment (vii) taking part in the PRINCE Secondary study or the ACTIB Study (Everitt et al., 2015).

Related Conditions & MeSH terms

• Persistent Physical Symptoms

Intervention

Behavioral:
• Integrated GP Care
The overall aims of the intervention are to help the patient: develop an understanding of the relationship between cognitive, emotional, physiological and behavioral aspects of their problem; understand factors that may be maintaining the problem; learn how to modify the behavioral and cognitive responses which may be maintaining the problem; adopt a healthy sleep routine which can promote healthy living. Hand-outs will be available for GPs to give to patients, but the structure of the intervention allows for treatment to be formulation-based so that particular issues raised in the consultation that might be maintaining symptom severity (e.g. avoidance) can be addressed.

Locations

Country	Name	City	State
United Kingdom	Kings College London	London

Sponsors (2)

Lead Sponsor	Collaborator
King's College London	South London and Maudsley NHS Foundation Trust

Country where clinical trial is conducted

United Kingdom, 

References & Publications (21)

Altayar O, Sharma V, Prokop LJ, Sood A, Murad MH. Psychological therapies in patients with irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials. Gastroenterol Res Pract. 2015;2015:549308. doi: 10.1155/2015/549308. Epub 2015 Jan 31. Review. — View Citation

Bermingham SL, Cohen A, Hague J, Parsonage M. The cost of somatisation among the working-age population in England for the year 2008-2009. Ment Health Fam Med. 2010 Jun;7(2):71-84. — View Citation

Brooks R. EuroQol: the current state of play. Health Policy. 1996 Jul;37(1):53-72. Review. — View Citation

Burton C, Weller D, Marsden W, Worth A, Sharpe M. A primary care Symptoms Clinic for patients with medically unexplained symptoms: pilot randomised trial. BMJ Open. 2012 Feb 9;2:e000513. doi: 10.1136/bmjopen-2011-000513. Print 2012. — View Citation

Chalder T, Wallace P, Wessely S. Self-help treatment of chronic fatigue in the community: A randomized controlled trial. British Journal of Health Psychology 1997;2(3):189-97. doi: https://doi.org/10.1111/j.2044-8287.1997.tb00535.x

Everitt H, Landau S, Little P, Bishop FL, McCrone P, O'Reilly G, Coleman N, Logan R, Chalder T, Moss-Morris R; ACTIB trial team. Assessing Cognitive behavioural Therapy in Irritable Bowel (ACTIB): protocol for a randomised controlled trial of clinical-effectiveness and cost-effectiveness of therapist delivered cognitive behavioural therapy and web-based self-management in irritable bowel syndrome in adults. BMJ Open. 2015 Jul 15;5(7):e008622. doi: 10.1136/bmjopen-2015-008622. — View Citation

Johansen ML, Risor MB. What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies. Patient Educ Couns. 2017 Apr;100(4):647-654. doi: 10.1016/j.pec.2016.11.015. Epub 2016 Nov 21. Review. — View Citation

Jonsbu E, Dammen T, Morken G, Moum T, Martinsen EW. Short-term cognitive behavioral therapy for non-cardiac chest pain and benign palpitations: a randomized controlled trial. J Psychosom Res. 2011 Feb;70(2):117-23. doi: 10.1016/j.jpsychores.2010.09.013. Epub 2010 Dec 3. — View Citation

Kennedy TM, Chalder T, McCrone P, Darnley S, Knapp M, Jones RH, Wessely S. Cognitive behavioural therapy in addition to antispasmodic therapy for irritable bowel syndrome in primary care: randomised controlled trial. Health Technol Assess. 2006 Jun;10(19):iii-iv, ix-x, 1-67. — View Citation

Kisely SR, Campbell LA, Skerritt P, Yelland MJ. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004101. doi: 10.1002/14651858.CD004101.pub3. Review. Update in: Cochrane Database Syst Rev. 2012;6:CD004101. — View Citation

Kleinstäuber M, Witthöft M, Hiller W. Efficacy of short-term psychotherapy for multiple medically unexplained physical symptoms: a meta-analysis. Clin Psychol Rev. 2011 Feb;31(1):146-60. doi: 10.1016/j.cpr.2010.09.001. Epub 2010 Sep 16. — View Citation

Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr;64(2):258-66. — View Citation

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. — View Citation

Moss-Morris R, Chalder T. Illness perceptions and levels of disability in patients with chronic fatigue syndrome and rheumatoid arthritis. J Psychosom Res. 2003 Oct;55(4):305-8. — View Citation

Mundt JC, Marks IM, Shear MK, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002 May;180:461-4. — View Citation

Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. J Psychosom Res. 2001 Jul;51(1):361-7. — View Citation

Reme SE, Stahl D, Kennedy T, Jones R, Darnley S, Chalder T. Mediators of change in cognitive behaviour therapy and mebeverine for irritable bowel syndrome. Psychol Med. 2011 Dec;41(12):2669-79. doi: 10.1017/S0033291711000328. Epub 2011 Apr 11. — View Citation

Salmon P, Peters S, Clifford R, Iredale W, Gask L, Rogers A, Dowrick C, Hughes J, Morriss R. Why do general practitioners decline training to improve management of medically unexplained symptoms? J Gen Intern Med. 2007 May;22(5):565-71. — View Citation

Sharpe M, Stone J, Hibberd C, Warlow C, Duncan R, Coleman R, Roberts R, Cull R, Pelosi A, Cavanagh J, Matthews K, Goldbeck R, Smyth R, Walker A, Walker J, MacMahon A, Murray G, Carson A. Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome. Psychol Med. 2010 Apr;40(4):689-98. doi: 10.1017/S0033291709990717. Epub 2009 Jul 23. — View Citation

van Dessel N, den Boeft M, van der Wouden JC, Kleinstäuber M, Leone SS, Terluin B, Numans ME, van der Horst HE, van Marwijk H. Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Syst Rev. 2014 Nov 1;(11):CD011142. doi: 10.1002/14651858.CD011142.pub2. Review. — View Citation

White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus BJ, Murphy G, Murphy M, O'Dowd H, Wilks D, McCrone P, Chalder T, Sharpe M; PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011 Mar 5;377(9768):823-36. doi: 10.1016/S0140-6736(11)60096-2. Epub 2011 Feb 18. — View Citation

* Note: There are 21 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Work and Social Adjustment Scale (WSAS)	a five-item scale with a range of scores from 0 to 40 (a higher score indicates more severe impairment) that is used to measure patients' own perceptions of the impact of PPS on their functioning in terms of work, home management, social leisure and private leisure activities, family and other relationships.	24 weeks post randomization
Other	Patient Health Questionnaire-15 (PHQ-15)	a 15-item scale measuring somatic symptoms and taking values from 0 to 30.	24 weeks post randomization
Other	Patient Health Questionnaire-9 (PHQ-9)	a 9-item scale measuring depressive symptoms taking values from 0 to 27, with scores of scores of 5, 10, 15, and 20 representing mild, moderate, moderately severe, and severe depression respectively (Kroenke, Spitzer & Williams, 2001).	24 weeks post randomization
Other	Clinical Global Impression (CGI)	a nine-point scale measuring patient's perceived improvement, where 1 is completely recovered and 9 is could not get any worse	24 weeks post randomization
Other	Satisfaction (Measure patients' self-rated satisfaction of the intervention)	Measure patients' self-rated satisfaction of the intervention.	24 weeks post randomization
Other	Client Service Receipt Inventory (Measures health care service receipt, direct and indirect costs of illness, and cost effectiveness of intervention)	questionnaire detailing patient's use of services, including: Use of care providers (yes/no and type); Attendance at accident and emergency (yes/no); Use of diagnostic tests (yes/no and type); Working hours, occupation and days absent from work; Receipt of benefits (yes/no and type)	24 weeks post randomization
Other	GPs knowledge Questionnaire	Measures GP knowledge: 10 true of false statements testing the GP's knowledge of PPS (maximum score of 11)	24 weeks post randomization
Other	GP's Confidence Questionnaire	Measures GP confidence: and a ten-item scale testing their confidence treating PPS (minimum score 10 and maximum score 70)	24 weeks post randomization
Other	Cognitive Behavioural Responses Questionnaire (CBRQ)	measure of putative mediators of cognitive change including: fear avoidance (range 0-24),; catastrophizing (range 0-16),; damage avoidance (range 0-20),; embarrassment avoidance (range 0-24),; symptom focusing (range 0-24),; all or nothing behaviour (range 0-20) and avoidance behaviour (range 0-32) (Reme, Stahl & Chalder, 2011)	24 weeks post randomization
Other	EuroQol - 5 Dimensions - 5 Levels (EuroQol-5D-5L)	a 5-item scale measuring health, taking from 5 to 25. Additionally, patients rate their own perceptions of their current health on a scale of 0 to 100 (Brooks, 1996).	24 weeks post randomization
Primary	Feasibility: Willingness of clinicians to participate in the study (proportion of GPs that register within the study out of the GPs that are registered with the eligible practice)	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Willingness of patients to use the provided material given in 'integrated GP care' (self-help material).	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Willingness of practices and participants to be contacted about the study (Number (No.) of reply slips sent via the post to ask if the practice/participants would like to participate further information v No. of reply slips received back)	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Willingness of practices to be randomised (No. of eligible GP practices agreed consent v No. of GP practices not agreed to consent)	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Willingness of GP practices to be consent and be randomized as assessed by No. of eligible GP practices agreed consent v No. of GP practices not agreed to consent	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Follow-up rates and response rates to questionnaires (Sent questionnaires v completed questionnaires received at 12 and 24 weeks).	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Rate of eligible trial participants (Consort). The number of patients per practice that are initially screened for eligibility and the number per practice meeting the inclusion and exclusion criteria.	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Availability of data required and the usefulness and limitations of GP databases assessed qualitatively	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization
Primary	Feasibility: Willingness of participants to be consented and randomised (No. of positive reply slips received V No. of patients agreed to be screened, No. of eligible patients agreed consent v No. of eligible patients not agreed to consent)	The following definition of a feasibility study has been agreed by the Efficacy and Mechanism Evaluation (EME), Public Health Research (PHR), Health Technology Assessment (HTA) and Research for Patient Benefit (RfPB) programme: "Feasibility Studies are pieces of research done before a main study in order to answer the question "Can this study be done?". They are used to estimate important parameters that are needed to design the main study".	24 weeks post randomization