Shared decision‐making behaviours in health professionals: a systematic review of studies based on the Theory of Planned Behaviour

Background

Shared decision making (SDM) requires health professionals to change their practice. Socio‐cognitive theories, such as the Theory of Planned Behaviour (TPB), provide the needed theoretical underpinnings for designing behaviour change interventions.

Objective

We systematically reviewed studies that used the TPB to assess SDM behaviours in health professionals to explore how theory is being used to explain influences on SDM intentions and/or behaviours, and which construct is identified as most influential.

Search strategy

We searched PsycINFO, MEDLINE, EMBASE, CINAHL, Index to theses, Proquest dissertations and Current Contents for all years up to April 2012.

Inclusion criteria

We included all studies in French or English that used the TPB and related socio‐cognitive theories to assess SDM behavioural intentions or behaviours in health professionals. We used Makoul & Clayman''s integrative SDM model to identify SDM behaviours.

Data extraction and synthesis

We extracted study characteristics, nature of the socio‐cognitive theory, SDM behaviour, and theory‐based determinants of the SDM behavioural intention or behaviour. We computed simple frequency counts.

Main results

Of 12 388 titles, we assessed 136 full‐text articles for eligibility. We kept 20 eligible studies, all published in English between 1996 and 2012. Studies were conducted in Canada (n = 8), the USA (n = 6), the Netherlands (n = 3), the United Kingdom (n = 2) and Australia (n = 1). The determinant most frequently and significantly associated with intention was the subjective norm (n = 15/21 analyses).

Discussion

There was great variance in the way socio‐cognitive theories predicted SDM intention and/or behaviour, but frequency of significance indicated that subjective norm was most influential.     

Exploring older and younger adults' preferences for health information and participation in decision making using the Health Information Wants Questionnaire (HIWQ)

Context

Existing measurements of patient preferences cover only a limited range of health information and participation in decision making. A broader approach is necessary to understand the breadth and variations in patient preferences.

Objective

To explore the breadth and variances in patient preferences for health information and participation in decision making and to understand the relationship between age and each type of preference.

Design

The Health Information Wants Questionnaire (HIWQ) was administered during May–December 2010 to gather data about the information and corresponding decision‐making autonomy participants would want in seven areas: diagnosis, treatment, laboratory tests, self‐care, complementary and alternative medicine (CAM), psychosocial factors and health‐care providers.

Setting

A large state university, public libraries and senior centres in Maryland, USA.

Participants

A convenience sample of 438 individuals, including 226 undergraduates (mean age = 20; SD = 2.15) and 212 community‐dwelling older adults (mean age = 72; SD = 9.00).

Main Outcome Measures

Ratings on the information and decision‐making items of the HIWQ.

Results

Participants expressed higher levels of preference for information than for participation in decision making on six of seven subscales. On the psychosocial subscale, they expressed stronger desire for participation in decision making than for information. Age had no predictive effect on the overall preferences or specific preferences for information and participation in decision making about standard treatments and CAM. The predictive effect of age on the other types of preferences varied significantly.

Conclusions

Physicians should take into account the breadth and variations in patient preferences. The predictive effect of age on patient preferences varied depending on the specific area of preferences.     

Assessments of the extent to which health‐care providers involve patients in decision making: a systematic review of studies using the OPTION instrument

Background

We have no clear overview of the extent to which health‐care providers involve patients in the decision‐making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this.

Objective

To systematically review studies that used the OPTION instrument to observe the extent to which health‐care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation.

Search strategy

We conducted online literature searches in multiple databases (2001–12) and gathered further data through networking.

Inclusion criteria

(i) OPTION scores as reported outcomes and (ii) health‐care providers and patients as study participants. For analysis, we only included studies using the revised scale.

Data extraction

Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting.

Main results

We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient‐involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0–100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15).

Conclusions

Whatever the clinical context, few health‐care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this.     

Impact of clinical and patient‐reported outcomes on patient satisfaction with cataract extraction

Background

To date, factors that influence satisfaction with cataract surgery have not been broadly explored.

Objective

To identify variables related to patient satisfaction after cataract extraction by phacoemulsification and to determine the relationship between satisfaction and visual acuity (VA) and visual function (VF).

Design

Prospective cohort study.

Setting

Five hospitals belonging to the Basque Health Care Service.

Participants

4335 consecutive patients undergoing cataract extraction.

Interventions

Clinical data on vision were collected before the intervention and 6 weeks afterwards. Before cataract extraction, patients answered a global question about their expectations for the procedure, answered three questions related to specific activities (reading, going out and recognizing people, and doing housework) and completed the Visual Function‐14 (VF‐14) and Short‐Form‐36 (SF‐36) instruments. Three months after cataract extraction, they again completed the VF‐14 and SF‐36 along with questions about global satisfaction with the procedure and satisfaction with the three specific activities.

Main outcome measures

Three months after cataract extraction, they again completed the VF‐14 and SF‐36 along with questions about global satisfaction with the procedure and satisfaction with the three specific activities.

Results

Pre‐intervention VA and VF‐14 scores and their post‐intervention changes were associated with both global satisfaction and satisfaction with the ability to perform specific activities. Unresolved ocular complications were related to global satisfaction with cataract extraction (OR _95% = 0.39_{(0.27, 0.55)}, P < 0.001). Both the mental and physical component scales of the SF‐36 were related to global satisfaction. A group of patients were not satisfied with the intervention in spite of achieving similar vision‐related improvements as patients who were quite satisfied with the procedure.

Conclusion

Satisfaction with cataract extraction is related to clinical outcomes and is also associated with patients'' expectations of their improvement in visual function.     

A systematic review of research into black and ethnic minority patients' views on self‐management of type 2 diabetes

Context

Eliciting patients'' views of type 2 diabetes self‐management provides insights on how policy and services might better support the needs of this population.

Objective

To synthesize black and ethnic minority patients'' views on the barriers and facilitators influencing the self‐management of type 2 diabetes.

Search strategy

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free‐text terms. Two relevant journals were also hand searched.

Inclusion criteria

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients'' views on type 2 diabetes self‐management.

Data extraction and synthesis

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

Main results

Fifty‐seven studies were included, of qualitative (n = 54), mixed‐method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: ‘Importance of identity’; ‘Being understood by others’ and ‘Making sense of condition’, all linked conceptually under the overarching theme ‘Sense of self’. The quality of the studies varied.

Discussion and conclusions

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self‐management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient‐centred care and policies.     

In search of compassion: a new taxonomy of compassionate physician behaviours

Background

Compassion has been extolled as a virtue in the physician–patient relationship as a response to patient suffering. However, there are few studies that systematically document the behavioural features of physician compassion and the ways in which physicians communicate compassion to patients.

Objective

To develop a taxonomy of compassionate behaviours and statements expressed by the physician that can be discerned by an outside observer.

Design

Qualitative analysis of audio‐recorded office visits between oncologists and patients with advanced cancer.

Setting and Participants

Oncologists (n = 23) and their patients with advanced cancer (n = 49) were recruited in the greater Rochester, New York, area. The physicians and patients were surveyed and had office visits audio recorded.

Main Outcome Measures

Audio recordings were listened to for qualitative assessment of communication skills.

Results

Our sensitizing framework was oriented around three elements of compassion: recognition of the patient''s suffering, emotional resonance and movement towards addressing suffering. Statements of compassion included direct statements, paralinguistic expressions and performative comments. Compassion frequently unfolded over the course of a conversation rather than being a single discrete event. Additionally, non‐verbal linguistic elements (e.g. silence) were frequently employed to communicate emotional resonance.

Discussion and Conclusions

This study is the first to systematically catalogue instances of compassionate communication in physician‐patient dialogues. Further refinement and validation of this preliminary taxonomy can guide future education and training interventions to facilitate compassion in physician–patient interactions.     

‘The onus is on me’: primary care patient views of Medicare‐funded team care in chronic disease management in Australia

Background and objective

This study investigated the views of primary care patients in receipt of Medicare‐funded team care for chronic disease management (CDM) in Australia.

Design

A qualitative study using a repeat in‐depth interview design.

Participants and setting

Twenty‐three patients (17 female), aged 32–89, were recruited over a six‐month period from two purposively selected general practices: one urban and one regional practice in Queensland, Australia.

Data collection procedure

Semi‐structured interviews were conducted with participants 6 months apart. An interview guide was used to ensure consistency of topics explored. Interviews were recorded and transcribed, and a thematic analysis was conducted.

Results

Patients in this study viewed the combined contributions of a GP and other health professionals in team care as thorough and reassuring. In this case of Medicare‐funded team care, patients also saw obligations within the structured care routine which cultivated a personal ethics of CDM. This was further influenced by how patients viewed their role in the health‐care relationship. Aside from personal obligations, Medicare funding got patients engaged in team care by providing financial incentives. Indeed, this was a defining factor in seeing allied health professionals. However, team care was also preferential due to patients'' valuations of costs and benefits.

Conclusion

Patients are likely to engage with a structured team care approach to CDM if there is a sense of personal obligation and sufficient financial incentive. The level of engagement in team care is likely to be optimized if patient expectations and preferences are considered in decisions.     

What primary health‐care services are Australian consumers willing to accept from nurse practitioners? A National Survey

Background

Nurses are becoming increasingly important as providers of primary health care in Australia. In November 2010, Medicare provider rights and Pharmaceutical Benefits Scheme rights for nurse practitioners, working in private practice and in collaboration with a medical practitioner, were introduced in Australia. Although international evidence suggests that nurse practitioners would be appropriate and acceptable providers of care at the first point of contact, such as primary health care, there is little Australian evidence about what care consumers are willing to accept from nurse practitioners.

Objectives

To ascertain what care Australian health‐care consumers would accept from nurse practitioners in this setting.

Participants

Australian adults over 18 years of age.

Methods

National Survey delivered online. Information about the survey was disseminated through a media campaign, stakeholder engagement and through the health‐care consumer networks nationally.

Results

The total number of respondents that started the survey was n = 1883. Ninety‐five percentage (n = 1784) of respondents completed the survey. The majority of respondents were women, aged 25–54 years, had completed tertiary education and had an annual household income of more than A$80 000. The majority of the respondents (n = 1562, 87%) said they would be prepared to see a nurse practitioner for some of their primary health‐care needs.

Conclusions

The findings of this study suggest consumers are accepting of a range of activities undertaken by nurse practitioners in primary health care and this has relevance for primary health‐care workforce mix and organization, particularly for areas that are underserved by medical practitioners.     

Development of a model to guide decision making in amyotrophic lateral sclerosis multidisciplinary care

Background

Patients with amyotrophic lateral sclerosis (ALS) face numerous decisions for symptom management and quality of life. Models of decision making in chronic disease and cancer care are insufficient for the complex and changing needs of patients with ALS .

Objective

The aim was to examine the question: how can decision making that is both effective and patient‐centred be enacted in ALS multidisciplinary care?

Setting and participants

Fifty‐four respondents (32 health professionals, 14 patients and eight carers) from two specialized ALS multidisciplinary clinics participated in semi‐structured interviews. Interviews were transcribed, coded and analysed thematically.

Results

Comparison of stakeholder perspectives revealed six key themes of ALS decision making. These were the decision‐making process; patient‐centred focus; timing and planning; information sources; engagement with specialized ALS services; and access to non‐specialized services. A model, embedded in the specialized ALS multidisciplinary clinic, was derived to guide patient decision making. The model is cyclic, with four stages: ‘Participant Engagement’; ‘Option Information’; ‘Option Deliberation’; and ‘Decision Implementation’.

Discussion

Effective and patient‐centred decision making is enhanced by the structure of the specialized ALS clinic, which promotes patients'' symptom management and quality of life goals. However, patient and carer engagement in ALS decision making is tested by the dynamic nature of ALS, and patient and family distress. Our model optimizes patient‐centred decision making, by incorporating patients'' cyclic decision‐making patterns and facilitating carer inclusion in decision processes.

Conclusions

The model captures the complexities of patient‐centred decision making in ALS. The framework can assist patients and carers, health professionals, researchers and policymakers in this challenging disease environment.     

Patient participation in medication safety during an acute care admission

Background

Patient participation in medication management during hospitalization is thought to reduce medication errors and, following discharge, improve adherence and therapeutic use of medications. There is, however, limited understanding of how patients participate in their medication management while hospitalized.

Objective

To explore patient participation in the context of medication management during a hospital admission for a cardiac surgical intervention of patients with cardiovascular disease.

Design

Single institution, case study design. The unit of analysis was a cardiothoracic ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. Multiple methods of data collection were used including pre‐admission and pre‐discharge patient interviews (n = 98), naturalistic observations (n = 48) and focus group interviews (n = 2).

Results

All patients had changes made to their pre‐operative cardiovascular medications as a consequence of surgery. More patients were able to list and state the purpose and side‐effects of their cardiovascular medications at pre‐admission than prior to discharge from hospital. There was very little evidence that nurses used opportunities such as medication administration times to engage patients in medication management during hospital admission.

Discussion and Conclusions

Failure to engage patients in medication management and provide opportunities for patients to learn about changes to their medications has implications for the quality and safety of care patients receive in hospital and when managing their medications once discharged. To increase the opportunity for patients to participate in medication management, a fundamental shift in the way nurses currently provide care is required.     

Barriers for an effective communication around clinical decision making: an analysis of the gaps between doctors' and patients' point of view

Background

There are doubts on whether patients feel that they have sufficient information for actively participating in clinical decisions.

Objective

To describe the type of information that patients receive. To determine whether patients consider this information sufficient, and whether it contributes or not to improve clinical safety. To identify the barriers for patient participation in clinical decision making.

Study Design

Cross‐sectional study with 764 patients and 327 physicians.

Study Setting and participants

Fourteen health centres belonging to three primary care districts and three hospitals in Spain.

Principal Findings

Just 35.1% (268) (95% CI 32.2, 39.1%) of patients preferred to have the last word in clinical decisions. Age (39 vs. 62%, P < 0.001) and severity of illness (38 vs. 46%, P = 0.002) increased the tendency to take a passive role. In 85.1% (650) (95% CI 83.3, 88.3%) of the cases, patients reported having received sufficient information. Lack of consultation time (29.6%, 95% CI 25.8, 32.5%) and patients'' use of Internet or other sources (19.2%, 95% CI 16.4, 22.2%) were identified as new obstacles to doctor–patient communication by the patients. Only 19.6% (64) (95% CI 15.4, 24.2%) of doctors considered that they could intervene to involve patients in the decisions.

Discussions and Conclusions

The majority of patients prefer the decisions to be made by their doctor, especially those with more severe illnesses, and older patients. Patients are not normally informed about medication interactions, precautions and foreseeable complications. The information provided by general practitioners does not seem to contribute enough to the patient involvement in clinical safety.     

Comparing the nine‐item Shared Decision‐Making Questionnaire to the OPTION Scale – an attempt to establish convergent validity

Background

While there has been a clear move towards shared decision‐making (SDM) in the last few years, the measurement of SDM‐related constructs remains challenging. There has been a call for further psychometric testing of known scales, especially regarding validity aspects.

Objective

To test convergent validity of the nine‐item Shared Decision‐Making Questionnaire (SDM‐Q‐9) by comparing it to the OPTION Scale.

Design

Cross‐sectional study.

Setting and participants

Data were collected in outpatient care practices. Patients suffering from chronic diseases and facing a medical decision were included in the study.

Methods

Consultations were evaluated using the OPTION Scale. Patients completed the SDM‐Q‐9 after the consultation. First, the internal consistency of both scales and the inter‐rater reliability of the OPTION Scale were calculated. To analyse the convergent validity of the SDM‐Q‐9, correlation between the patient (SDM‐Q‐9) and expert ratings (OPTION Scale) was calculated.

Results

A total of 21 physicians provided analysable data of consultations with 63 patients. Analyses revealed good internal consistency of the SDM‐Q‐9 and limited internal consistency of the OPTION Scale. Inter‐rater reliability of the latter was less than optimal. Association between the total scores of both instruments was weak with a Spearman correlation of r = 0.19 and did not reach statistical significance.

Discussion

By the use of the OPTION Scale convergent validity of the SDM‐Q‐9 could not be established. Several possible explanations for this result are discussed.

Conclusion

This study shows that the measurement of SDM remains challenging.     

Mapping the impact of patient and public involvement on health and social care research: a systematic review

Background

There is an increasing international interest in patient and public involvement (PPI) in research, yet relatively little robust evidence exists about its impact on health and social care research.

Objective

To identify the impact of patient and public involvement on health and social care research.

Design

A systematic search of electronic databases and health libraries was undertaken from 1995 to 2009. Data were extracted and quality assessed utilizing the guidelines of the NHS Centre for Reviews and Dissemination 2009 and the Critical Appraisal Skills Programme (CASP). Grey literature was assessed using the Dixon‐Woods et al. (2005) checklist.

Inclusion criteria

All study types that reported the impact PPI had on the health and/or social care research study.

Main results

A total of 66 studies reporting the impact of PPI on health and social care research were included. The positive impacts identified enhanced the quality and appropriateness of research. Impacts were reported for all stages of research, including the development of user‐focused research objectives, development of user‐relevant research questions, development of user‐friendly information, questionnaires and interview schedules, more appropriate recruitment strategies for studies, consumer‐focused interpretation of data and enhanced implementation and dissemination of study results. Some challenging impacts were also identified.

Conclusion

This study provides the first international evidence of PPI impact that has emerged at all key stages of the research process. However, much of the evidence base concerning impact remains weak and needs significant enhancement in the next decade.     

How do people interpret information about colorectal cancer screening: observations from a think‐aloud study

Background

The English NHS Bowel Cancer Screening Programme biennially invites individuals aged 60–74 to participate in screening. The booklet, ‘Bowel Cancer Screening: The Facts'' accompanies this invitation. Its primary aim is to inform potential participants about the aims, advantages and disadvantages of colorectal cancer screening.

Objective

To provide detailed commentary on how individuals process the information contained within ‘The Facts’ booklet.

Design, setting and participants

This study comprised of 18 interviews with individuals aged 45–60 and used a ‘think‐aloud’ paradigm in which participants read aloud the booklet. Participant utterances (verbal statements made in response to researcher‐led prompts) were transcribed and analysed using a combination of content and thematic analysis.

Results

A total of 776 coded utterances were analysed (mean = 43.1 per person; range = 8–95). While overall comprehension was satisfactory, several problem areas were identified such as the use of complex unfamiliar terminology and the presentation of numerical information. Specific sections such as colonoscopy risk information evoked negative emotional responses. Participants made several suggestions for ways in which comprehension might be improved.

Conclusion

Public perceptions of the NHS Bowel Cancer Screening Programme information materials indicated that specific aspects of the booklet were difficult to process. These materials may be an appropriate target to improve public understanding of the aims, benefits and disadvantages of colorectal cancer screening. These findings will contribute to a broader NIHR‐funded project that aims to design a supplementary ‘gist‐based’ information leaflet suitable for low literacy populations.     

Multidisciplinary diabetes team care: the experiences of young adults with Type 1 diabetes

Background

This research examined whether young adults with Type 1 diabetes engage with the multidisciplinary consultation process and if not, then why.

Methods

We designed a web‐based self‐reported survey, available online from February to May 2011, for Australian adults 18–35 years with Type 1 diabetes. Respondents were asked about which clinicians they consulted to assist with self‐management. To expand on the results of the survey, we interviewed 33 respondents.

Results

Survey: Respondents (n = 150) consulted with the following clinicians: endocrinologist and diabetes educators: 23.3%; endocrinologist only: 18.0%; endocrinologist, diabetes educators and dieticians: 14.6%; endocrinologist, diabetes educators, dietician and general practitioners (GP): 11.3%; endocrinologist and GP: 10.6%; GP only: 4.6%; all clinicians recommended to assist with self‐management: 1.3%; 2.7% did not consult any clinician. Interview: Participants (n = 33) reported eight key disincentives to consultation with multidisciplinary clinicians. These were time constraints; provision of conflicting advice; inaccessibility of health services; variation in service standards; cost constraints; failure of clinicians to refer to other clinicians; lack of opportunity to build a therapeutic relationship; and failure of clinicians to engage in shared decision making.

Conclusion

Our results indicate that high attrition rates of young adults with Type 1 diabetes from recommended diabetes health services is linked to the failure of those services to meet the needs and preferences of their patients. The identified needs and preferences included joint consultation with multi‐disciplinary team clinicians; flexible access to advice by email or telephone consultation; and shared decision making. Patient engagement in health‐service re‐design has implications for improved health‐service delivery and enhanced treatment outcomes.     

Effect of intervention on decision making of treatment for disease progression,prostate‐specific antigen biochemical failure and prostate cancer death

Background

Patient preference for the choice of treatment modality for prostate cancer has increasingly gained attention.

Objective

To assess the impact of client‐oriented decision on long‐term mortality, disease progression and biochemical failure compared with standard treatment protocol (TP).

Methods

With data from a Finnish multicentre, randomized controlled trial with two arms [104 in the enhanced patient participation (EPP) arm and 106 in the TP arm], disease‐specific and disease‐free survival, biochemical failure with elevated prostate‐specific antigen (PSA) level and disease progression were compared between the two arms using Wilcoxon test and also Cox proportional hazards regression model.

Results

Patients in the EPP arm had a higher risk of death by 37% [HR, 1.37 (0.87–2.17)] compared with those in the TP arm. Patients in the EPP arm were at increased risk of having biochemical failure by 14% [HR, 1.14 (0.72–1.79)] and for having disease progression by 2% [HR, 1.02 (0.61–1.70)] compared with those in the TP arm. All the differences were non‐significant.

Conclusions

Patients actively involved in the choice of treatment had higher risk of prostate cancer death but only slightly increased risk of biochemical failure and clinical disease progression. These findings would provide a good reference when patient autonomy for the choice of treatment modality is addressed.     

Is the Give Youth a Voice questionnaire an appropriate measure of teen‐centred care in paediatric oncology: a Rasch measurement theory analysis

Background

Adolescents have their own views about the cancer care they receive and how they feel they are treated, but their opinions are rarely solicited.

Objective

To determine whether the 56‐item Give Youth a Voice (GYV‐56), its subscales and its 20‐item short‐form, are clinically meaningful and psychometrically sound instruments that can be used to measure teen‐centred care (TCC) in paediatric oncology.

Design

Qualitative interviews and a questionnaire survey.

Setting and participants

Qualitative interviews with 38 childhood cancer survivors. GYV‐56 data collected from 200 paediatric cancer patients and survivors.

Main outcome measure

The GYV‐56, which measures the following four aspects of service delivery: Supportive and respectful relationships; Information sharing and communication; Supporting independence; and Teen‐centred services.

Results

Qualitative data provided broad support for the TCC conceptual framework and GYV‐56 items. After post‐hoc reduction of the response options from 7 to 3 (to correct for disordered thresholds), fit to the Rasch model was good, most items showed acceptable fit residuals and chi‐square P‐values, scale reliability were supported and item locations defined a continuum for TCC that was well‐targeted to the sample. By calibrating the items for each subscale and the short‐form to the full scale, the scores obtained on each measure are directly comparable.

Conclusion

Our study found initial support for use of the GYV with a reduced response option format for examining TCC in the adolescent oncology patients. in this paediatric population. Further research using the GYV is needed to elaborate upon our findings.     

Patient perceptions of patient‐centred care: empirical test of a theoretical model

Aim

Patient perception measures are gaining increasing interest among scholars and practitioners. The aim of this study was to empirically examine a conceptual model of patient‐centred care using patient perception survey data.

Background

Patient‐centred care is one of the Institute of Medicine''s objectives for improving health care in the 21st century. Patient interviews conducted by the Picker Institute/Commonwealth Fund in the 1980s resulted in a theoretical model and survey questions with dimensions and attributes patients defined as patient‐centered.

Method

The present study used survey data from patients with overnight visits at 142 U.S. hospitals.

Results

Regression analysis found significant support for the theoretical model. Perceptions of emotional support had the strongest relationship with overall care ratings. Coordination of care, and physical comfort were strongly related as well.

Conclusion

Understanding how patients experience their care can help improve understanding of what patients believe is patient‐centred, and of how care processes relate to important patient outcomes.     

Values and risks of second opinion in Japan's universal health‐care system

Background

Second opinion (SO) is widely recognized in Japan, but we do not know how patients view and use SO.

Objectives

To investigate optimum seeking of SO in Japan''s universal health‐care system.

Design, participants, and methods

Survey of patients at Tokyo Medical and Dental University Hospital. Of 365 responses, 67 had experienced SO with standardized protocol at SO Clinic; 82 had obtained SO elsewhere without instruction; 216 had never sought SO.

Main outcome measures

Views of values and risks of SO.

Results

Second opinion patients with standardized protocol better understood their illness, treatment options, individualized plan, and uncertainty in medicine, and also reported improved decision making compared with SO patients without the protocol (P < 0.05). However, more than half of respondents misunderstood SO as a way to change doctors or treatment. Second opinion respondents (n = 149) had a propensity to request treatment changes (P < 0.1) and more than one‐third (n = 82) did not tell SO doctor they were being treated by another doctor. The absolute majority of non‐SO patients would seek SO for a serious illness but would hesitate to tell their doctors.

Discussion and conclusion

Respondents recognized value of SO to improve understanding and decision making. This study also found risks in SO misuse which may be reinforced by Japan''s cultural tendencies and universal health‐care system. Our findings suggest steps to increase the benefit of SO: ensure involvement of original doctor, instruct patients about SO and help them organize their thinking before SO and facilitate patients'' return to the treating doctor for discussion and decision making.