Patient trust: is it related to patient-centered behavior of primary care physicians?

BACKGROUND: Patients' trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. METHODS: We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physician's practice and to SPs. We used multilevel modeling to examine the associations between physicians' Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. RESULTS: Component 1 of the MPCC, which explored the patient's experience of the disease and illness, was independently associated with patient's rating of trust in their physician. A I SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02-0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001-0.02). Component 1 and visit length were also positively associated with SP trust ratings. CONCLUSIONS: Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians' exploration patients' experiences of disease and illness improves trust. Key Words: physician-patient relationship, patient-centered care, trust, physician behavior     

Physician referral rates: style without much substance?

BACKGROUND: Primary care physicians (PCPs) exhibit widely varying referral rates, resulting in dramatic differences in the exposure of their patients to specialists. The relationships between this physician behavior and costs and patient outcomes are unknown. OBJECTIVES: To examine the relationships between PCP referral rates and costs, risk of avoidable hospitalization, health status, and satisfaction. DESIGN: Cross-sectional analyses of claims and patient survey data. SETTING AND SUBJECTS: Independent practice association (IPA)-style managed care organization in the Rochester, NY, metropolitan area. The 1995 claims data included 457 PCPs in the IPA and 217,606 adult patients assigned to their panels. Approximately 50 consecutive patients of each of a random sample of 100 PCPs completed a patient survey in 1997-1998. MEASURES: From the claims data, total expenditures per panel member, the risk of avoidable hospitalization, and physician referral rate were measured. Measures derived from the survey included SF-12 scores, satisfaction, and physician referral rate. RESULTS: The relationship between physician referral rate and per-panel-member costs was not statistically significant after case-mix adjustment of the referral rate. There was no relationship between the case-mix-adjusted referral rate and risk of avoidable hospitalization. In the survey data, there was no adjusted relationship between the physicians' referral rate and their patients' self-rated physical or mental health. There was a modest direct relationship between patient satisfaction and survey-derived referral rate. CONCLUSIONS: Despite stable, wide variations in PCP referral rates, there are few discemible relationships between this physician behavior and costs and patient outcomes. Efforts to constrain PCP referrals to specialists may be misguided.     

Activities of home-based heart failure nurse specialists: a modified narrative analysis.

BACKGROUND: Heart failure nurse specialists strive to optimize patients' outcomes in home-based settings. OBJECTIVE: To document the activities of home-based heart failure nurse specialists. METHOD: A modified narrative analysis of clinical notes of home-based heart failure nurse specialists during a 12-month period was used. RESULTS: Data analysis revealed 7 key activities of home-based heart failure nurse specialists: (1) monitoring signs and symptoms and reinforcing patients' self-management: identifying trends and appropriate action; (2) organization, liaison, and consultation with other health professionals to deal with changes in clinical status; (3) clarifying and reinforcing patients' self-care strategies; (4) assisting patients in their desire to avoid institutionalized care; (5) identifying patients' psychosocial issues: dealing with social isolation; (6) providing support: journeying with patients and patients' families; and (7) helping patients and patients' families deal with death and dying. CONCLUSIONS: A major proportion of the activities of home-based heart failure nurse specialists are related to facilitating communication between health professionals and providing information and support to patients and patients' families.     

Care process and patient outcome in diabetes mellitus.

The relationship between the process of medical care and patient outcome is a central issue in health services research. We examined this relationship in 244 patients with adult-onset diabetes mellitus, who were under the care of private internists and family physicians. Process measures included physician awareness of patients' concerns, communication of information from physician to patient, medication-taking behavior, physician adherence to minimum care criteria, and extent of patient utilization of services. Outcomes measured during and after a 6-month follow-up period, included diabetic control status and patient satisfaction with medical care. Potentially confounding variables included practice and physician characteristics, patient demographic characteristics, and measures of disease severity. There was a small statistically significant correlation between physician awareness and control status, but the association was not maintained when controlling for other variables. Communication of information from physician to patient was significantly (p less than .005) associated with satisfaction in the multiple regression analysis but explained only 4 per cent of the variance in patient satisfaction. Thus, in patients under treatment for diabetes, there was little association between certain measures of care process and patient outcome. We suggest that process and outcome assessments are distinct but complementary aspects of quality of care.     

Inaccuracies in physicians' perceptions of their patients.

OBJECTIVE: The objective was to assess primary care physicians' awareness of their patients' rated emotions, satisfaction, and opinion of the quality of their communication. DESIGN: Diabetic patients (n = 261) and their primary care physicians (n = 44) each filled in a questionnaire following a routine medical visit. Patients were asked about the quality of communication with their physician, their satisfaction, and their experience of six emotions. Physicians were asked to estimate the patients' views on each of these questions. Physicians' awareness was measured by (1) correlating the physician and patient ratings, and (2) comparing mean ratings between physicians and patients. RESULTS: Correlations between patients' and physicians' views of patients' emotions and satisfaction were weak to moderate in magnitude; for patients' opinion of communication quality, there was no correlation. All ratings showed a substantial discrepancy between physicians and patients, such that physicians thought patients' responses were more negative than they actually were. CONCLUSIONS: Although the causes of physicians' weak awareness of their patients' responses are not known, the results suggest that the patients' affective responses may be an especially neglected aspect of communication in the medical visit.     

Further validation and reliability testing of the Trust in Physician Scale. The Stanford Trust Study Physicians.

OBJECTIVES: To further validate and assess the reliability and validity of the Trust in Physician Scale. METHODS: Consecutive adult patients (n = 414) from 20 community-based, primary care practices were enrolled in a prospective, 6-month study. At enrollment, subjects completed the 11-item Trust in Physician Scale plus measures of demographics, preferences for care, and satisfaction with care received from the physician. Continuity, satisfaction with care, and self-reported adherence to treatment were measured at 6 months. Reliability, construct validity, and predictive validity were assessed using correlation coefficients and analysis of variance techniques. RESULTS: The Trust in Physician Scale showed high internal consistency (Cronbach's alpha = .89) and good 1-month test-retest reliability (intraclass correlation coefficient = .77). As expected, trust increased with the length of the relationship and was higher among patients who actively chose their physician, who preferred more physician involvement, and who expected their physician to care for a larger proportion of their problems (P < 0.001 for all associations). Baseline trust predicted continuity with the physician, self-reported adherence to medication, and satisfaction at 6 months after adjustment for gender, age, education, length of the relationship, active choice of the physician, and preferences for care. After additional adjustment for baseline satisfaction with physician care, trust remained a significant predictor of continuity, adherence, and satisfaction. CONCLUSIONS: The Trust in Physician Scale has desirable psychometric characteristics and demonstrates construct and predictive validity. It appears to be related to, but still distinct from, patient satisfaction with the physician and, thus, provides a valuable additional measure for assessment of the quality of the patient-physician relationship.     

Nurse Practitioner Communication and Treatment Adherence in Hypertensive Patients

In hypertensive patients, treatment adherence is improved with patient-centered communication (PTC), leading to better outcomes. Many barriers to PTC should be overcome, including patient background characteristics, provider time constraints, and provider discomfort. Using patient-centered education increases patient awareness of choices and builds a partnership between the provider and patient. Nurse practitioners should adhere to PTC by discussing the disease of hypertension, treatment, and self-monitoring. Overcoming communication barriers will lead to better patient understanding, trust, satisfaction, improved treatment plans, greater adherence, and improved blood pressure.     

Patient education before discharge from the hospital

Hospitalized patients' perception of their physician's effectiveness as a patient educator was surveyed, using three basic areas of doctor-patient communication: diagnoses, medications, and follow-up plans. The survey instrument, a questionnaire designed and administered by medical students, was designed to ascertain (1) the patients' satisfaction with their hospital stay, (2) satisfaction with their physician as a patient educator, (3) any correlation between (1) and (2), and finally (4) specific data about the amount and kind of information that patients perceived had been transferred from their physician. Satisfaction with their doctor as a patient educator was not a good predictor of satisfaction with the hospital stay. Results are compared with those of a similar survey published in the British medical literature. The effectiveness of the resident physicians as patient educators increased as they were given more information about the exact content of the survey. Their increased effectiveness did not clearly persist during a later follow-up period.     

Interventions to improve patient-centered care during times of emergency department crowding

Patient-centered care is defined by the Institute of Medicine (IOM) as care that is responsive to individual patient needs and values and that guides treatment decisions. This article is the result of a breakout session of the 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" and focuses on three broad domains of patient-centered care: patient satisfaction, patient involvement, and care related to patient needs.The working group provided background information and an overview of interventions that have been conducted in the domains of patient satisfaction, patient involvement (patients' preferences and values in decision-making), and patient needs (e.g., comfort, information, education). Participants in the breakout session discussed interventions reported in the medical literature as well as initiated at their institutions, discussed the effect of crowding on patient-centered care, and prioritized, in a two-step voting process, five areas of focus for establishing a research agenda for studying patient-centered care during times of crowding. The research priorities for enhancing patient-centered care in all three domains during periods of crowding are discussed. These include assessing the effect of other quality domains on patient satisfaction and determining the effects of changes in ED operations on patient satisfaction; enhancing patient involvement by determining the effect of digital records and health information technology (HIT); rapid assessment areas with focused patient-provider communication; and meeting patients' needs through flexible staffing, use of HIT to enhance patient communication, discharge instructions, and postdischarge telephone calls.     

皮肤科门诊设立病人接待中心工作模式的探讨

目的皮肤科门诊设立病人接待中心,提高医院服务质量和病人满意度。方法从细节做起,开展咨询、导医、个性化服务、健康教育等工作,拓宽服务范围。结果把以病人为中心落到实处,真正满足病人的就医需求,为病人提供更优质的服务。结论为病人提供多角度、全方位的就医服务,能提高医院服务质量和病人的满意度,不断满足病人的医疗服务需求。     

Nurse practitioners' communication styles and their impact on patient outcomes: an integrated literature review

Purpose: The purpose of this review was to examine the published research from 1999 to 2005 describing nurse practitioner (NP)–patient interactions and to determine the best practice to enhance patient outcomes.
Data sources: Databases searched included Academic Search Elite, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Source Consumer Edition, Health Source Nursing/Academic Edition, Medline, and PsychInfo.
Conclusions: Two communication styles described in the literature and determined by authors were (a) biomedical and (b) biopsychosocial. The biopsychosocial style is identified as patient-centered communication. Seven studies were then analyzed for NPs' communication styles and the impact that they had on patient outcomes. The studies analyzed demonstrated that biopsychosocial (patient-centered) communication style positively influences patient outcomes as evidenced by (a) improved patient satisfaction, (b) increased adherence to treatment plans, and (c) improved patient health.
Implications for practice: The results of this review indicate that patient-centered communication incorporated into the NPs' practice is associated with improving patient outcomes such as (a) improved patient satisfaction, (b) increased adherence to treatment plans, and (c) improved patient health. Future research needs to be performed in order to fully study the relationship between NPs using patient-centered communication style and its impact on patient outcomes. Clinical recommendations are made based on findings of the integrated literature review.     

Stages of change for adherence with medication regimens for chronic disease: development and validation of a measure

BACKGROUND: The stages-of-change (SOC) model has been used to explain and predict how behavior change occurs, but it is new as an approach to understanding why patients fail to take their medications as prescribed. OBJECTIVE: This study validated a 2-item measure of SOC for adherence with medication regimens in 2 groups of patients prescribed pharmacologic therapy for chronic conditions. METHODS: Two cross-sectional studies of attitudes toward medication adherence included the same measure of SOC for medication adherence. One was a sample of 161 HIV-positive patients in the United States, and the other was an international sample of 731 patients with hypertension. The validity of the measure of SOC for medication adherence was examined in both convenience samples using previously validated self-reported measures of adherence (the Medication Adherence Scale and a measure of adherence from the Medical Outcomes Study), and in the HIV sample using electronic monitoring of adherence behavior in 85 patients. RESULTS: Construct validity was demonstrated in both samples by associations between SOC and the previously validated measures of adherence (P < 0.001), and predictive validity was supported by significant associations between SOC for medication adherence and electronically monitored medication-taking behavior during the next 30 days (P < 0.03). CONCLUSIONS: Behavior-change theory suggests that stage-tailored communication strategies are more effective than uniform health-promotion messages. Our results provide a foundation for the development of interventions for medication adherence that are tailored to patients' readiness for change. Our validated 2-item measure of SOC for medication adherence can be used to match communication strategies to individual motivation and readiness for adherence with chronic disease medication regimens.     

Medicaid participation by medical and surgical specialists

Most studies of physician participation in Medicaid have focused on primary care physicians, but access by the poor to specialists' services is also a policy concern. This study examined Medicaid participation rates for a national sample of 2291 private practice physicians in nine medical and surgical specialties. Four fifths of the specialists treated at least some Medicaid patients, with an average case load of 11.2% Medicaid patients, rates very similar to those obtained elsewhere for primary care physicians. Surgical specialists, especially ophthalmologists, otolaryngologists, and urologists, were the most willing to participate, and cardiologists were the least willing. Multivariate analysis confirmed the importance of Medicaid programmatic characteristics on both physician entry and level of participation. A 10% increase in the Medicaid fee would raise specialist participation by 3%. Other factors encouraging participation included faster claims processing, fewer limits on the quantity of services covered, and more generous eligibility criteria.     

The patient's signature of the physician's report at discharge from rehabilitation

What follows for the outcome of rehabilitation, patients' satisfaction and work organisation in a rehabilitation hospital if the patients obtain their discharge reports for signature before they leave? This has been investigated in a pilot study at the University Rehabilitation Hospital in Bad Wurzach, Germany. The pilot study was so successful that the hospital continued to use the new procedure. Only very few refused their signature, most patients were happy to obtain their discharge reports immediately and to have the opportunity to discuss the report with their physician if desired. Physician judged patients' participation slightly more pointly while the known discrepancies between physicians' and patients' point of view remained, i. e. the physician doesn't "touch up" knowing the patient will read his report. Integrating the patient in the process is a major step towards patients' empowerment. Both the influence on patients' satisfaction and changes in work organisation are discussed in the paper. A timely discharge examination and an optimised computer-supported workflow, transformation of loosely coupled activities in a process managed by time frames are preconditions for being able to have the discharge report ready before the patients leave. Monitoring the timely delivery then becomes obsolete.     

Factors that affect adherence to bipolar disorder treatments: a stated-preference approach

BACKGROUND: Medication nonadherence is high among patients with bipolar disorder, and may lead to poor clinical outcomes, decreased quality of life, and increased resource utilization. OBJECTIVE: To investigate the factors associated with nonadherence and to assess the effect of patient-stated preferences on stated adherence to hypothetical medications. RESEARCH DESIGN: A choice-format stated-preference Web survey was administered. In each choice question, patients were asked to choose among 2 or 3 different hypothetical medications. Each choice question was followed by a question asking patients about their likely adherence to the selected medication alternative. SUBJECTS: Patients (N = 469) with self-reported bipolar disorder completed the survey which was programmed and administered to members of a chronic-illness Web panel. MEASURES: Factors associated with stated adherence to current treatment were identified. The effects of socioeconomic characteristics and medication attributes on stated adherence to hypothetical medications were assessed. RESULTS: Patient socioeconomic characteristics affect patients' adherence. Being white and having more education has a significant positive effect on adherence. Self-reported current adherence is a strong factor in predicting adherence for better medications. Medication outcome attributes, especially severity of depressive episodes, strongly influence patients' stated adherence to treatment. Weight gain and cognitive effects of a medication most significantly affected patients' likely adherence to medications for bipolar disorder. CONCLUSIONS: Patients are the final health care decision makers; their satisfaction with a medication is likely to affect whether or not they adhere to the medication prescribed by their physician. In the case of bipolar disorder, this study suggests patients are likely to be more adherent to medications that reduce the severity of depressive episodes and do not cause weight gain or cognitive side effects. By understanding the factors that improve adherence, health care providers can optimize prescribing patterns, which may ultimately lead to more effective management and improvement in the patient's condition.     

Satisfaction with Family Physicians and Specialists and the use of Complementary and Alternative Medicine in Israel

Higher utilization of complementary and alternative medicine (CAM) is commonly explained by dissatisfaction or disappointment with conventional medical treatment. To explore, at two points in time in Israel, the associations between six domains of satisfaction (attitude, length of visits, availability, information sharing, perceived quality of care and overall) with conventional family physicians' and specialists' services and the likelihood of consulting CAM providers. This is a secondary analysis of interviews, which were conducted with 2000 persons in 1993 and 2500 persons in 2000, representing the Israeli Jewish urban population aged 45-75 in those years. Bivariate and multivariate analyses were used in the investigation. In 1993, users of CAM were less satisfied than non-users with both family physicians' and specialists' care. Lower satisfaction with the attitude of, the amount of information sharing by and in general with family physicians, and with the length of visits and perceived quality of care of specialists were significantly associated with CAM use. In 2000, lower satisfaction with specialists' attitude, length of visits, availability and in general was significantly related to the use of CAM. Lower satisfaction with family physicians and specialists is significantly associated with consulting CAM providers. However, with CAM becoming a mainstream medical care specialty in its own, lower satisfaction with conventional medicine specialists becomes the most important factor.     

An initial experience with telemedicine in follow-up burn care

Following care in a burn unit, regular outpatient visits with burn specialists are required. The practical use of telemedicine in this context is unknown. The objective of this study was to evaluate patient and physician satisfaction with teleconsultations in follow-up burn care and to assess the costs and benefits of these teleconsultations. Fourteen teleconsultations were conducted between a burn physician and a patient at a remote site. Patients and the physician completed evaluation questionnaires for each teleconsultation. Time-related and financial costs of the consultation service were also determined. Patients were very satisfied with their teleconsultations and found them more economical and time efficient than in-person visits. The consulting physician felt teleconsultations were as satisfactory as clinic visits for the purposes of diagnosis and burn management. Our results support the ongoing use of telemedicine in the follow-up care of burn patients.     

Measuring intensive care nurses' perspectives on family-centered end-of-life care: evaluation of 3 questionnaires.

BACKGROUND: Attempts to improve end-of-life care increasingly focus on family-centered care, but few validated assessment tools exist. OBJECTIVES: To evaluate 3 new short questionnaires measuring nurses' perspectives on family-centered end-of-life care in the intensive care unit and to show the usefulness of the questionnaires. METHODS: Principal components analysis of data from 141 critical care nurses evaluating care given to families of 218 patients was used to develop domain scores for number of nursing activities with each family, number of barriers experienced, and nurses' satisfaction that the family's needs were met. Random effects models were used to test associations between critical care processes and outcome. RESULTS: Nursing activities fell into 2 domains: general and culture-related communication/support. Barriers consisted of 2 domains: patient/family barriers and system/team barriers. Meeting the needs of patients' families represented a single dimension. In a path model based on domain scores, general activities had significant associations with both nurse communication and meeting families' needs; patient/family barriers, with nurse communication; and nurse and physician communication, with meeting families' needs. In a path model based on total activities and barriers scores, total activities and total barriers had significant associations with nurse communication ratings and meeting families' needs. Patients' and nurses' characteristics were not significant independent predictors of meeting the needs of patients' families. CONCLUSIONS: The 3 questionnaires provide a consistent, valid picture of nurses' perspectives on family-centered critical care and may be useful in evaluating family care processes and outcomes and in targeting areas for improvement.