An evidence base for patient-centered cancer care: A meta-analysis of studies of observed communication between cancer specialists and their patients

Objective

In the context of patients visiting cancer specialists, the objective is to test the association between both patient-centered communication (including Affective Behavior and Participation Behavior) and Instrumental Behavior and patients’ post-visit satisfaction with a variety of visit phenomena.

Methods

Meta-analysis of 25 articles representing 10 distinct data sets.

Results

Both patient-centered- and instrumental behavior are significantly, positively associated with satisfaction, with patient-centered communication having a relatively stronger association.

Conclusion

There is an evidence base for the efficacy of patient-centered care.

Practice implications

Cancer specialists need to train to improve their patient-centered communication.     

Psychometric evaluation and design of patient-centered communication measures for cancer care settings

ObjectiveTo evaluate the psychometric properties of questions that assess patient perceptions of patient-provider communication and design measures of patient-centered communication (PCC).MethodsParticipants (adults with colon or rectal cancer living in North Carolina) completed a survey at 2 to 3 months post-diagnosis. The survey included 87 questions in six PCC Functions: Exchanging Information, Fostering Health Relationships, Making Decisions, Responding to Emotions, Enabling Patient Self-Management, and Managing Uncertainty. For each Function we conducted factor analyses, item response theory modeling, and tests for differential item functioning, and assessed reliability and construct validity.ResultsParticipants included 501 respondents; 46% had a high school education or less. Reliability within each Function ranged from 0.90 to 0.96. The PCC-Ca-36 (36-question survey; reliability=0.94) and PCC-Ca-6 (6-question survey; reliability=0.92) measures differentiated between individuals with poor and good health (i.e., known-groups validity) and were highly correlated with the HINTS communication scale (i.e., convergent validity).ConclusionThis study provides theory-grounded PCC measures found to be reliable and valid in colorectal cancer patients in North Carolina. Future work should evaluate measure validity over time and in other cancer populations.Practice implicationsThe PCC-Ca-36 and PCC-Ca-6 measures may be used for surveillance, intervention research, and quality improvement initiatives.     

Defining and implementing patient-centered care: An umbrella review

ObjectivesPatient- or person-centered care (PCC) integrates people’s preferences, values, and beliefs into health decision-making. Gaps exist for defining and implementing PCC; therefore, we aimed to identify core elements of PCC and synthesize implementation facilitators and barriers.MethodsWe conducted an overview of systematic reviews (umbrella review) and included peer-reviewed literature for adults in community/primary care settings. Two reviewers independently screened at Level 1 and 2, extracted data and appraised the quality of reviews. Three reviewers conducted a thematic analysis, and we present a narrative synthesis of findings.ResultsThere were 2371 citations screened, and 10 systematic reviews included. We identified 10 PCC definitions with common elements, such as patient empowerment, patient individuality, and a biopsychosocial approach. Implementation factors focused on communication, training healthcare providers, and organizational structure.ConclusionsWe provide a synthesis of key PCC elements to include in a future definition, and an overview of elements to consider for implementing PCC into practice. We extend existing literature by identifying clinician empowerment and culture change at the systems-level as two future areas to prioritize to enable routine integration of PCC into practice.Practice implicationsFindings may be useful for researchers and or health providers delivering and evaluating PCC.     

A method to determine the impact of patient-centered care interventions in primary care

Objective

The implementation of patient-centered care (PCC) innovations continues to be poorly understood. We used the implementation effectiveness framework to pilot a method for measuring the impact of a PCC innovation in primary care practices.

Methods

We analyzed data from a prior study that assessed the implementation of an electronic geriatric quality-of-life (QOL) module in 3 primary care practices in central North Carolina in 2011–2012. Patients responded to the items and the subsequent patient–provider encounter was coded using the Roter Interaction Analysis System (RIAS) system. We developed an implementation effectiveness measure specific to the QOL module (i.e., frequency of usage during the encounter) using RIAS and then tested if there were differences with RIAS codes using analysis of variance.

Results

A total of 60 patient–provider encounters examined differences in the uptake of the QOL module (i.e., implementation-effectiveness measure) with the frequency of RIAS codes during the encounter (i.e., patient-centeredness measure). There was a significant association between the effectiveness measure and patient-centered RIAS codes.

Conclusion

The concept of implementation effectiveness provided a useful framework determine the impact of a PCC innovation.

Practice implications

A method that captures real-time interactions between patients and care staff over time can meaningfully evaluate PCC innovations.     

The importance of patient-centered care for various patient groups

Objectives

To assess differences in the importance ascribed to patient-centered care between various patient groups and demographic groups.

Methods

Survey data collected using questionnaires were analyzed for patients that underwent hip or knee surgery (n = 214), patients suffering from rheumatoid arthritis (n = 343), spinal disk herniation (n = 145), breast abnormalities (n = 596) or congestive heart failure (n = 118). A composite for patient-centered care priorities was constructed (α = 0.82) and compared to the average importance over all healthcare aspects in the surveys.

Results

All patient groups considered patient-centered care to be of above-average importance (p‘s < 0.001). Small but significant differences were observed: patient-centered care was more important for patients suffering from congestive heart failure (p < 0.001) and patients who were younger, female, well-educated and healthier (p‘s < 0.05). Patients who had undergone hip or knee surgery considered patient-centered care more important than patients with spinal disk herniation did (p < 0.05).

Conclusion

Patient-centered care is important to all patient groups. Differential policies regarding patient-centered care for patient subgroups do not seem required.

Practical implications

Given the importance attributed to patient-centered care, it is essential that elements of patient-centered care are included in surveys, indicators of quality of care, and the training of doctors and nurses.     

Eye contact in patient-centered communication

Objective

To understand the relationship between eye contact and patient-centered communication (PC) in physician-elder patient interactions.

Methods

Two instruments—Patient-centered Behavior Coding Instrument (PBCI) and Eurocommunication Global Ratings Scale—were used to measure PC in 22 National Institute of Aging videotapes. Eye contact was measured using a refined eye contact scale in NDEPT. Qualitative observational techniques were used to understand how eye contact can implicate communication.

Results

‘High’ eye contact tapes were found to be ‘high’ in PC using both instruments. However, the majority of ‘low’ tapes were also found to be ‘high’ in PC. Physicians’ behavior distinctly differed in two ways: (1) high tapes were characterized by more ‘sustained’ eye contact episodes; low tapes consisted of a greater number of ‘brief’ episodes; (2) brief episode tapes showed a greater focus on ‘charts’, i.e. ‘listening’ was bereft of ‘looking’; sustained episodes showed a focus on ‘patients’, i.e. ‘listening’ was accompanied by ‘looking’ indicating patient-centered communication.

Conclusions

A comprehensive understanding of elder patient-physician interaction needs to include both—‘listening’ and ‘looking’—components of patient-centered communication.

Practice implications

Eye contact serves as a salient factor in the expression of PC, making it imperative to incorporate as a nonverbal dimension in PC instruments.     

The communicative role of companion pets in patient-centered critical care

Objective

This study examines a personal pet hospital visitation program dedicated to preserving the human-animal bond during chronic, critical, or terminal illness to understand the novel ways companion pets facilitate meaningful communication between patients, providers, and families in hospital settings.

The impact of patient-centered communication on patients' decision making and evaluations of physicians: a randomized study using video vignettes

Objective

To assess the impact of patient-centered communication (PCC) behaviors on patients’ evaluations of physicians and acceptance of clinical recommendations.

Methods

We randomized 248 patients to view video-recorded, standardized vignettes, depicting a cardiologist using a high vs. low degree of PCC while recommending bypass surgery to a patient with angina and 3-vessel coronary artery disease. We compared patients’ ratings of the physician and their decision making in response to the physician's recommendation, for high vs. low PCC vignettes.

Results

Patients viewing high PCC vignettes rated the video physician more favorably overall (3.01 vs. 2.12, p < 0.001) and as more competent (3.22 vs. 2.66, p < 0.001) and trustworthy (2.93 vs. 2.28, p < 0.001) than those viewing the low PCC version (0-4 range for all scales). Patients viewing the high PCC version more frequently said they would undergo bypass surgery (96% vs. 74%, p < 0.001) if they were the patient in the video.

Conclusion

Patients expressed greater confidence in physicians who used more PCC behaviors, and greater willingness to accept an evidence-based recommendation.

Practice implications

PCC may make physicians more effective in the delivery of evidence-based care.     

Language barriers and patient-centered breast cancer care

Objective

Provision of high quality patient-centered care is fundamental to eliminating healthcare disparities in breast cancer. We investigated physicians’ experiences communicating with limited English proficient (LEP) breast cancer patients.

Methods

Survey of a random sample of California oncologists and surgeons.

Results

Of 301 respondents who reported treating LEP patients, 46% were oncologists, 75% male, 68% in private practice, and on average 33% of their patients had breast cancer. Only 40% reported at least sometimes using professional interpretation services. Although 75% felt they were usually able to communicate effectively with LEP patients, more than half reported difficulty discussing treatment options and prognosis, and 56% acknowledged having less-patient-centered treatment discussions with LEP breast cancer patients. In multivariate analysis, use of professional interpreters was associated with 53% lower odds of reporting less-patient-centered treatment discussions (OR 0.47; 95% CI 0.26-0.85).

Conclusion

California surgeons and oncologists caring for breast cancer patients report substantial communication challenges when faced with a language barrier. Although use of professional interpreters is associated with more patient-centered communication, there is a low rate of professional interpreter utilization.

Practice implications

Future research and policy should focus on increasing access to and reimbursement for professional interpreter services.     

Relationship of patient-centered communication and cancer risk information avoidance: A social cognitive perspective

ObjectiveWe examined the relationship between patient-centered communication and cancer risk information avoidance and estimated the mediating role of self-efficacy in this relationship.MethodsUsing nationally representative cross-sectional data from the U.S. Health Information National Trends Survey (N = 2033), this study aims to provide a comprehensive understanding of the relationship between patient-centered communication and cancer risk information avoidance via correlation analysis, stepwise regression models, and mediation analysis.ResultsPatient-centered communication was significantly negatively associated with cancer risk information avoidance (β= −0.09, p < 0.01) after controlling for gender, income, education, and cancer risk perception. Self-efficacy fully mediated the relationship of patient-centered communication with cancer risk information avoidance.ConclusionPatient-centered communication can improve patients’ self-efficacy, thereby preventing them from avoiding cancer risk information.Practice implicationsThe negative relationship between patient-centered communication and cancer risk information avoidance substantiates that improving patient-centered communication is a promising approach to support caregivers in their activities, reduce patients’ subjective cancer burden, and even improve their health. To address cancer-related issues, policymakers can consider interventions from the external environment and internal personal cognition perspectives.     

Latina contraceptive decision-making and use: The importance of provider communication and shared decision-making for patient-centered care

BackgroundPoor patient-provider communication, among other reasons, is a notable barrier to contraceptive decision-making among Latinas. Patient-centered approaches to contraceptive counseling that optimize communication align with shared decision-making (SDM) –which is associated with satisfaction and continued contraceptive use among various populations.ObjectiveTo examine associations of patient-provider communication and importance of SDM tenets with consistent contraceptive use among a population of Latinas.Patient involvementFormative work for this study included prior qualitative and quantitative research with Latinas who expressed the importance of patient-provider communication during contraceptive counseling and therefore were instrumental in problem definition.MethodsCross-sectional surveys were administered to Latinas ages 15–29 years. Patient-provider communication, patient-reported importance of specific SDM tenets, and consistent contraception use were measured and analyzed for associations.Results103 Latinas (mean age = 21.4) participated. 33% of participants<21 years were using contraception consistently vs. 67% for those ≥ 21 (p = 0.003). Among participants ≥ 21, consistent users reported higher communication scores compared to inconsistent users and non-users (p = 0.042). For participants< 21, consistent users were more likely than inconsistent users and non-users to report that 2 SDM tenets (discussion of contraceptive preferences and avoidance of race/ethnic-based judgement) are important (p = 0.052, 0.028, respectively).DiscussionPatient-provider communication was especially important for Latinas ≥ 21 while using an SDM approach during counseling was highly valued by those<21. Patient-centered approaches to contraceptive counseling provide opportunities to optimize healthcare delivery for this vulnerable population.Practical valueResults from this research demonstrate that patient-centered communication is highly valued by Latina study participants and is an important consideration in their contraceptive counseling. Clinicians should consider employing techniques such as SDM as they seek to provide patient-centered care during contraceptive counseling for this patient population.     

Exploring patient-centeredness: The relationship between self-reported empathy and patient-centered communication in medical trainees

Objective

To explore the relationships between self-reported Empathy and the patient-centered communication patterns of physician trainees.

Determinants and outcomes of patient-centered care

Objective

This paper defines an interactional analysis instrument to characterize patient-centered care and identify associated variables.

Methods

In this study, 509 new adult patients were randomized to care by family physicians and general internists. An adaption of the Davis Observation Code was used to measure a patient-centered practice style. The main outcome measures were visit-specific satisfaction and healthcare resource utilization.

Results

In initial primary care visits, patient-centered practice style was positively associated with higher patient self-reported physical health status (p = 0.0328), higher educational level (p = 0.0050), and non-smoking status (p = 0.0108); it was also observed more often in the interactions of family physicians compared to internists (p = 0.0003). Controlling for patient sociodemographic variables, self-reported health status, pain, health risk behaviors (obesity, alcohol abuse, and smoking), and clinic assignment, patient satisfaction was not related to the provision of patient-centered care. Moreover, a higher average amount of patient-centered care recorded in visits throughout the one-year study period was significantly related to lower annual medical charges (p = 0.0003).

Conclusions

Patient-centered care was observed more often with family physician caring for healthier, more educated patients, and was associated with lower charges.

Practice implications

Reduced annual medical care charges are an important outcome of patient-centered medical visits.     

Impact of a brief faculty training to improve patient-centered communication while using electronic health records

Objective

Despite rapid EHR adoption, few faculty receive training in how to implement patient-centered communication skills while using computers in exam rooms. We piloted a patient-centered EHR use training to address this issue.

Training health professionals in patient-centered communication during magnetic resonance imaging to reduce patients’ perceived anxiety

ObjectiveWe examined how a patient-centered communication training program for magnetic resonance imaging (MRI) affected health professional (HP) practice and patients’ perceived anxiety (PA).MethodsWe implemented an intervention program. Six of the 17 eligible HPs completed the study. The proportion of observed desired behaviors (PODBs), including MRI procedure explanation (MRI-PE), communication, and MRI checking procedures was measured using an observation grid. We tested 182 patients (85 pre-, 58 post-, and 39 at follow-up) for PA pre- and post-MRI.ResultsThe Bayesian ANOVA effect size suggested moderate evidence of improvement in HP PODBs, pre- to post-intervention. Use of MRI-PE declined between post-intervention and follow-up (6 months later). Observed changes in PA, pre- to post-MRI, could be related to time constraints and perceived pressure to explain the exam in detail once institutional routines are reestablished.ConclusionIn MRI units, time constraints condition the performance of HPs who address patients’ PA.Practice implications“Real workplace” interventions that promote better patient-centered communication and provide each patient with a comprehensive explanation of MRI procedures also appear to improve HP PODBs.     

Predictors of weight loss communication in primary care encounters

Objective

Evidence suggests that physicians’ use of motivational interviewing (MI) techniques helps patients lose weight. We assessed patient, physician, relationship, and systems predictors of length of weight-loss discussions and whether physicians’ used MI techniques.

Methods

Forty primary care physicians and 461 of their overweight or obese patients were audio recorded and surveyed.

Results

Weight-related topics were commonly discussed (nutrition 78%, physical activity 82%, and BMI/weight 72%). Use of MI techniques was low. A multivariable linear mixed model was fit to time spent discussing weight, adjusting for patient clustering within physician. More time was spent with obese patients (p = .0002), by African American physicians (p = .03), family physicians (p = .02), and physicians who believed patients were embarrassed to discuss weight (p = .05). Female physicians were more likely to use MI techniques (p = .02); African American physicians were more likely to use MI-inconsistent techniques (p < .001).

Conclusion

Primary care physicians routinely counsel about weight and are likely to spend more time with obese than with overweight patients. Internists spend less time on weight. Patient and systems factors do not seem to influence physicians’ use MI techniques.

Practice implications

All physicians, particularly, male and African American physicians, could increase their use of MI techniques to promote more weight loss among patients.     

Patient-centered communication in digital medical encounters

ObjectivePatients are increasingly using the secure messaging function available through online patient portals to communicate with their health care providers, yet little is known about the characteristics of conversations that occur. The goal of this study is to describe the types of messages initiated by patients communicating via patient portals and to assess whether providers employ patient-centered strategies in their electronic responses.DesignA total of 193 messages from 58 message threads between patients and providers were collected during a one-week period in a large health care system.MethodsContent analysis of patient messages was conducted and deductive analysis of provider responses was employed for two types of patient-centered communication, provider use of supportive talk and partnership building.ResultsPatients sent nearly double the number of messages compared to providers (65% versus 35%). Patient messages expressed concern, sought medical solutions and requested assistance with administrative tasks. Over half (53.4%) of provider replies did not contain language reflective of either partnership building or supportive talk.ConclusionPartnership building language and supportive talk occurred at lower rates than documented in the literature on in-person encounters. This may represent a lost opportunity to strengthen the patient-provider relationship.Practice implicationsAs secure messaging is increasingly utilized as a form of patient-provider communication, it is important to understand how aspects of this communication channel, including the patient-centeredness of the language used by providers, impact patient-provider relationships and patient outcomes.