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2003 National Healthcare Quality Report

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Chapter 6. Patient Centeredness

Contents

Background and Impact
How the NHQR Measures Patient Centeredness of Care
How the Nation Is Doing
What We Don't Know
What Can Be Done
List of Measures
References

Key Findings:

  • Approximately 59% of adults responded that their health care provider always explained things clearly to them, while 9% reported that they were only sometimes or never provided clear explanations.
  • About 69% of parents surveyed felt their child's health care provider always explained things clearly to them, while 6% reported that they only sometimes or never did.
  • About 46% of adults indicated that their provider always spent enough time with them, while 16% reported that they only sometimes or never did.
  • Approximately 57% of the parents surveyed felt that their child's health care provider always spent enough time with them, while 10% said that they only sometimes or never did.

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Background and Impact

The mission of health care professionals and the health care system is to help patients maintain health, get well, and feel better. One way to achieve this mission is by a commitment and specific processes to ensure patients are at the center of the system and patients are a vital part of their own care.

"Patient centeredness" is defined as: "[H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care."1 Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the need, values, and expressed preferences of the individual patient."2

Communication is key to achieving patient-centered care. Research shows that the manner in which patients and clinicians communicate with each other can have an impact on patient satisfaction and quality of care.3 Good patient-provider communication can help patients be heard, get the information they need, and fully participate in decisionmaking concerning their own care. Various studies have shown that effective patient-provider communication may:

  • Lead to greater patient satisfaction.4
  • Increase the likelihood that patients have access to essential medical and preventive health information.5
  • Improve the chances that medical conditions are properly diagnosed (by ensuring that the doctor has more complete information).5
  • Increase the patient's participation in decisionmaking about his or her medical conditions.
  • Improve the chances that patients carry out health-related behavior modifications (e.g., exercising, quitting smoking, eating healthier, and complying with other treatments).6
  • Reduce the number of complaints and lawsuits filed against providers. For example, plaintiffs in malpractice claims include dysfunctional delivery of information in 25% of filed cases and poor listening by the provider in 8%-13% of filed cases.7

Improving patient-centered care can involve a range of different aspects and activities. Providers can improve their communication skills through the use of patient-centered questioning techniques such as sequenced questioning,8 humor, positive reinforcement, expressions of empathy, reassurance and support, and summarization and clarification.6,9 Educating patients so that they more effectively communicate their concerns to their doctors is a complementary approach. One study showed that patients directly voice their concerns only about one-fourth of the time.10

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How the NHQR Measures Patient Centeredness of Care

This report uses four indicators from personal response data collected by the Medical Expenditure Panel Survey. In the survey, adult patients and parents of patients under the age of 18 years were asked the following questions:

  • Did the health care provider listen carefully? — It is important for providers to listen to patients, since they must rely on them for information about symptoms and other information bearing on medical conditions and treatments. It is also important for the provider to listen because patients and physicians often have different views of symptoms and treatment effectiveness.11
  • Did the health care provider explain things clearly? — Providers often use medical terminology that patients do not understand, and patients may be too intimidated by the provider or simply lack the necessary understanding and skill to ask for clarification.5 This may lead to patient noncompliance with the recommended treatment.5
  • Did the health care provider show respect for what you had to say? — Respect for the patient's values, preferences, and expressed needs is one of several important dimensions of patient-centered care.12
  • Did the health care provider spend enough time with you? — A frequently raised concern is that patients are not allowed enough time with their doctors during visits. There is evidence that patients' concerns about time may be based on factors other than actual objectively measured consultation time (i.e., concerns may be more about quality time rather than actual time).13

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How the Nation Is Doing

The results from MEPS provide a baseline for tracking future progress in providing more patient-centered care. The results from the 2000 survey are provided below, both for adults and the parents of children under the age of 18 years. The responses show some variation among population groups. Overall, parents of children seeking care consistently showed higher levels of satisfaction than adults seeking care. For the following four measures, near poor/low-income respondents were less likely to answer "always."

Did the health care provider listen carefully?

Adults. Fifty-seven percent of people surveyed responded that their health care provider always listened carefully to them, 33% said usually, and 10% said they were only sometimes or never listened to carefully.

Children. Sixty-six percent of parents surveyed responded that their child's health care provider always listened carefully to them, 28% said usually, and 6% said they were only sometimes or never listened to carefully.

Did the health care provider explain things clearly to you?

Adults. Overall, 59% of those surveyed responded that their health care provider always explained things clearly to them, 32% said usually, and 9% reported that they were only sometimes or never provided clear explanations.

Children. About 69% of parents surveyed felt their child's health care provider always explained things clearly to them, 25% said usually, and 6% reported that they only sometimes or never did.

Did the health care provider show respect for what you had to say?

Adults. Some 59% of respondents reported that their health care provider always showed respect for what they had to say, 31% said usually, and 10% said that their health care providers only sometimes or never did. Those who reported their health as fair or poor were more likely to report that they were not shown respect.

Children. About 68% of the parents surveyed responded that their child's health care provider always showed respect for what they had to say, 26% said usually, and 6% said that their health care providers only sometimes or never showed them respect.

Did the health care provider spend enough time with you

Adults. Compared with results for the other three questions, respondents were less satisfied with the amount of time they spent with their health care provider. Only about 46% of adults reported that their provider always spent enough time with them, 38% said usually, and 16% reported that they only sometimes or never did.

Children. Some 57% of the parents surveyed felt that their child's health care provider always spent enough time with them, 33% said usually, and 10% said that they only sometimes or never did.


i Adjusting for known contributing factors, such as gender, age, and insurance status (multivariate analysis), would allow for more detailed exploration of the data, but this generally was not feasible for this report. Any adjustments that were done are noted in the detailed tables. The data presented in this report do not imply causation.


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What We Don't Know

The implications of patient preferences for the provider and for the provision of quality care are sometimes more complicated than they may at first appear, especially with the knowledge differential that exists between patient and physician. It has been demonstrated that a patient-centered approach can lead to improvements in quality of care. There currently are some limitations to what is known and can safely be said about this approach. One observation is that to be effective, patient-centered care has to take into account the individual variation that exists among patients. A few examples of this variability and complexity are provided below.

  • Many patients do not want to be informed about their care.14
  • Even when patients want to be informed about their medical condition and options for treatment, they may not wish to be actively involved in the decisionmaking process.14
  • Studies have shown conflicting results on relationships between information-seeking behaviors and patient satisfaction.15

These factors suggest that it is important for providers to recognize and accommodate the variability in the preferences of individuals.16 These factors also suggest the need for more research into the attributes and characteristics of patient-centered care.

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What Can Be Done

Only recently have patient centeredness and patient assessments of their care experience been recognized as important dimensions of quality of care. Research is being conducted into a variety of areas related to patient centeredness, including development of assessment instruments, public reporting of patient assessment data, and various techniques to improve communication between health professionals and patients. AHRQ has been developing a series of CAHPS® surveys and similar surveys for hospital care, nursing home care, and care in other settings and working to promote the application of these instruments in improving health care for all Americans.17

CMS has joined with AHRQ to develop and implement a version of CAHPS® for Medicare enrollees who are making choices among managed care plans. Many State programs, such as those for State employees in Kansas and Washington and Medicaid enrollees in New Jersey, have been using CAHPS® to assess their patient experience of care. Beginning in spring 1999, all health plans have been required to report patient assessments of care data on quality to NCQA for accreditation purposes. A national repository for data from the CAHPS® family of surveys, the National CAHPS® Benchmarking Database (NCBD), was initiated in 1998 to support benchmarking and research related to consumer assessments of care. All sponsors of CAHPS® surveys that are administered according to CAHPS® specifications are invited to participate in the NCBD.a Participating sponsors receive a customized report that compares their own results to appropriate benchmarks derived from the NCBD. Survey sponsors include public and private purchasers (employers, State Medicaid agencies, and Medicare) and individual health plans. It is expected that such patient centeredness data will be widely available to compare quality across institutions and patient groups and track changes over time.

The effectiveness of reporting data on patient centeredness is still being researched. For example, research suggests that patient-centered communication can be efficiently incorporated into medical encounters if clinicians learn the appropriate skills.18

More research is needed to understand patients' reporting of their experiences and how improved understanding and information help clinicians to better communicate with patients.

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List of Measures

Patient Centeredness

Measure Title National State
Patient experience of care:
% of patients who report that doctor listens carefully (always, usually, sometimes/never), adults and parents of children Table 4.1a (adult)
Table 4.1b (child)
Table 4.1c (a mcaid (27))
Table 4.1d (c mcaid (32))
Table 4.2e (mc FFS (30))
Table 4.2f (mc manc (32))
% of patients who report that doctor explains things clearly (always, usually, sometimes/never), adults and parents of children Table 4.2a (adult)
Table 4.2b (child)
Table 4.2c (a mcaid (29))
Table 4.2d (c mcaid (34,38)
Table 4.2e (mc FFS (31))
Table 4.2f (mc manc (33))
% of patients who report that doctor showed respect for what they had to say (always, usually, sometimes/never), adults and parents Table 4.3a (adult)
Table 4.3b (child)
Table 4.3c (a mcaid (30))
Table 4.3d (c mcaid (35))
Table 4.3e (mc FFS (32))
Table 4.3f (mc manc (34))
% of patients who report that doctor spent enough time with them (always, usually, sometimes/never), adults and parents of children Table 4.4b (child) Table 4.4a (adult) Table 4.4c (a mcaid (31))
Table 4.4d (c mcaid (39))
Table 4.4e (mc FFS (33))
Table 4.4f (mc manc (35))

Note: See Tables Appendix for tables listed above.

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References

1 Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academies Press; 2001. p. 50.

2 Institute of Medicine. Crossing the quality chasm. Washington, DC: National Academies Press; 2001. pp. 50-51. Available at: http://books.nap.edu/catalog.php?record_id=10027.Exit Disclaimer Accessed December 18, 2003.

3 Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49(9):796-804.

4 Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues 2002;16(12):80-2.

5 DiMatteo MR. The role of the physician in the emerging health care environment. West J Med 1998;168(5):329.

6 Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002;15(1):25-38.

7 Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002;15(1):35.

8 Lang F, Floyd MR, Beine KL, et al. Sequenced questioning to elicit the patient's perspective on illness: effects on information disclosure, patient satisfaction, and time expenditure. Fam Med 2002;34(5):325-30.

9 Clark W, Lipkin M, Graman H, et al. Improving physicians' relationships with patients. J Gen Intern Med 1999;14 Suppl 1:S45-50.

10 Post DM, Cegala DJ, Miser WF. The other half of the whole: teaching patients to communicate with physicians. Fam Med 2002;34(5):344.

11 Rhoades DR, McFarland KF, Finch WH, et al. Speaking and interruptions during primary care office visits. Fam Med 2001;33(7):528-32.

12 Institute of Medicine. Crossing the quality chasm. Washington, DC: National Academies Press; 2001. p. 52. Available at: http://books.nap.edu/catalog.php?record_id=10027. Exit Disclaimer Accessed December 18, 2003.

13 Cape J. Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract 2002;52(485):1004-6.

14 Robinson A, Thomson R. Variability in patient preferences for participating in medical decision making: implication for the use of decision support tools. Qual Health Care 2001;10 Suppl 1:i34-8.

15 Williams S, Weinman J, Dale J. Doctor-patient communication and patient satisfaction: a review. Fam Pract 1998;15(5):480-92.

16 Stewart M, Meredith L, Brown JB, et al. The influence of older patient-physician communication on health and health-related outcomes. Clin Geriatr Med 2000;16(1):25-36, vii-viii.

17 Agency for Healthcare Research and Quality. From the pipeline of health services research—CAHPS®: the story of the Consumer Assessment of Health Plans. AHRQ Publication No. 00-P014. 2000 Jan. Available at: http://www.ahrq.gov/research/cahptrip.htm. Accessed December 26, 2003.

18 Fortin AH 6th. Communication skills to improve patient satisfaction and quality of care. Ethn Dis 2002;12(4):S3-58-61.

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