Chapter 5. Patient Centeredness
National Healthcare Quality Report, 2011
The Institute of Medicine identifies patient centeredness as a core component of quality health care (IOM, 2001a). 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 (IOM, 2001b).
Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient" (IOM, 2001a). In addition, translation and interpretation services facilitate communication between the provider and the patient and are often a legal requirement.i The patient-centered approach includes viewing the patient as a unique person, rather than focusing strictly on the illness, building a therapeutic alliance based on the patient's and the provider's perspectives.
Patient-centered care is supported by good provider-patient communication so that patients' needs and wants are understood and addressed and patients understand and participate in their own care (IOM, 2001b). This approach to care has been shown to improve patients' health and health care (DiMatteo, 1998; Stewart, et al., 2000; Little, et al., 2001; Anderson, 2002; Beck, et al., 2002). Unfortunately, many barriers exist to good communication.
Providers also differ in communication proficiency, including varied listening skills and different views from their patients of symptoms and treatment effectiveness (Rhoades, et al., 2001). Additional factors influencing patient centeredness and provider-patient communication include:
- Language barriers.
- Racial and ethnic concordance between the patient and provider.
- Effects of disabilities on patients' health care experiences.
- Providers' cultural competency.
Efforts to remove these possible impediments to patient centeredness are underway within the Department of Health and Human Services (HHS). For example, the Office of Minority Health has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help promote patient-centered care (HHS, 2011).ii These modules are based on the National Standards on Culturally and Linguistically Appropriate Services. The standards are directed at health care organizations and aim to improve the patient centeredness of care for people with limited English proficiency (LEP). Another example, which is being administered by the Health Resources and Services Administration, is Unified Health Communication, a Web-based course for providers that integrates concepts related to health literacy with cultural competency and LEP.iii
Similarly, the HHS Office for Civil Rights, in partnership with 18 medical schools in the National Consortium for Multicultural Education, funded by the National Institutes of Health, provides a course on cultural competency in medicine that focuses on Title VI compliance, "Stopping Discrimination Before It Starts: The Impact of Civil Rights Laws on Health Care Disparities."iv This course discusses, in part, the HHS Office for Civil Rights' Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. This guidance explains that recipients of Federal financial assistance must take reasonable steps to provide LEP people with a meaningful opportunity to participate in HHS-funded programs. Failure to do so may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq., against national origin discrimination (HHS, 2008).
In addition, the HHS Office for Civil Rights is responsible for the enforcement of Section 1557 of the Affordable Care Act, 42 U.S.C. 18116, which provides that an individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. (race, color, national origin), Title IX of the Education Amendments of 1972, 20 U.S.C. 1681 et seq. (sex), the Age Discrimination Act of 1975, 42 U.S.C. 6101 et seq. (age), or Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794 (disability), under any health program or activity, any part of which is receiving Federal financial assistance, or under any program or activity that is administered by an executive agency or any entity established under Title I of the Affordable Care Act or its amendments.
Morbidity and Mortality
- Patient-centered approaches to care have been shown to improve patients' health status. These approaches rely on building a provider-patient relationship, improving communication, fostering a positive atmosphere, and encouraging patients to actively participate in provider-patient interactions (Stewart, et al., 2000; Anderson, 2002).
- A patient-centered approach has been shown to lessen patients' symptom burden (Little, et al., 2001).
- Patient-centered care encourages patients to comply with treatment regimens (Beck, et al., 2002).
- Patient-centered care can reduce the chance of misdiagnosis due to poor communication (DiMatteo, 1998).
- Patient centeredness has been shown to reduce underuse and overuse of medical care (Berry, et al., 2003).
- Patient centeredness can reduce the strain on system resources and save money by reducing the number of diagnostic tests and referrals (Little, et al., 2001).
- Although some studies have shown that being patient centered reduces medical costs and use of health service resources, others have shown that patient centeredness increases providers' costs, especially in the short run (Bechel, et al., 2000).
The National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) track several measures of patients' experience of care. The reports also address the priority of ensuring that each person and family are engaged as partners in their care, found in the National Strategy for Quality Improvement in Health Care.v The rationale is that "[h]ealth care should give each individual patient and family an active role in their care. Care should adapt readily to individual and family circumstances, as well as differing cultures, languages, disabilities, health literacy levels, and social backgrounds." Examples of person-centered care could be ensuring that patients' feedback on their preferences, desired outcomes, and experiences of care is integrated into care delivery and enabling patients to effectively manage their care.
The NHQR has tracked a growing number of patient centeredness measures. Organized around the National Strategy for Quality Improvement in Health Care, the 2011 NHQR presents the following measures that relate to the goal to provide patient-centered care:
- Adults and children who reported poor communication at the doctor's office (composite).
- Adults who reported poor communication with nurses and doctors.
- Provider's involvement of the patient in making treatment decisions.
Patients' Experience of Care—Adults
Optimal health care requires good communication between patients and providers, yet barriers to provider-patient communication are common. To provide all patients with the best possible care, providers need to understand patients' diverse health care needs and preferences and communicate clearly with patients about their care.
Figure 5.1. Adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers: Overall composite, by age and activity limitation, 2002-2008
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population age 18 and over who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.
- From 2002 to 2008, there was no statistically significant change in the percentage of adults ages 45-64 or age 65 and over with a doctor's office or clinic visit who reported poor communication (Figure 5.1). The percentage of patients ages 18-44 reporting poor communication decreased.
- From 2002 through 2008, a significantly lower percentage of adults ages 45-64 and age 65 and over reported poor communication with their health providers compared with adults ages 18-44 (in 2008, 8.9% and 6.4%, respectively, compared with 11.5%).
- From 2002 through 2008, the percentage of people reporting poor communication with their health provider was significantly higher for those with basic and complex activity limitations than for those with no activity limitations.
Also, in the NHDR:
- In 2008, Hispanic patients were significantly more likely than non-Hispanic Whites to report poor communication with health providers.
- In 2008, Black patients were more likely than White patients to report poor communication.
Patients' Experience of Care—Children
Communication in children's health care can be challenging since the child's experiences are interpreted through the eyes of a parent or guardian. During a health care encounter, a responsible adult caregiver will be involved in communicating with the provider and interpreting decisions in an age-appropriate manner to the patient. Optimal communication in children's health care can therefore have a significant impact on receipt of high-quality care and subsequent health status.
Figure 5.2. Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers: Overall composite, by age and special health care needs, 2002-2008
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population under age 18 who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.
- From 2002 to 2008, there was a statistically significant decrease for both age groups of children whose parents reported poor communication (Figure 5.2). During the same period, there was a statistically significant decrease for both gender groups as well (data not shown).
- In 2008, 4.4% of parents of children who had a doctor's office or clinic visit in the last 12 months reported poor communication with health providers. This rate is a significant improvement over the 2002 rate of 6.7% (data not shown).
- In 2002, 2004, 2006, and 2008, the percentage of people who reported poor communication was higher for children with special health care needs than for children without special health care needs.
Also, in the NHDR:
- From 2002 to 2008, the percentage of children whose parents or guardians reported poor communication with their health providers decreased for all racial, ethnic, and insurance groups, with the exception of children who were uninsured.
Patients' Experience of Care—Hospital
Using methods developed for the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey (Hargraves, et al., 2003), the NHQR and NHDR use a composite measure that combines three measures of provider-patient communication into a single core measure. The composite measure presented includes data on providers who sometimes or never listened carefully, explained things clearly, and respected what patients had to say. These data are presented separately for communication with nurses and communication with doctors.
Figure 5.3. Adult hospital patients who reported poor communication with nurses and doctors, by age, 2008
Source: Agency for Healthcare Research and Quality, Hospital CAHPS® (Consumer Assessment of Healthcare Providers and Systems) Survey, 2008.
Note: For this measure, lower rates are better. Poor communication is defined as responded "sometimes" or "never" to the set of survey questions: "During this hospital stay, how often did doctors/nurses treat you with courtesy and respect?" "During this hospital stay, how often did doctors/nurses listen carefully to you?" and "During this hospital stay, how often did doctors/nurses explain things in a way you could understand?"
- Overall, 5.6% of adult hospital patients reported poor communication with nurses during their hospital stay, and 5.3% reported poor communication with doctors (Figure 5.3).
- In 2008, patients age 65 and over were less likely to report poor communication with nurses compared with patients ages 18-44 (5.1% compared with 5.9%).
- Patients ages 45-64 were more likely to report poor communication with doctors compared with patients ages 18-44 (5.7% compared with 5.0%).
Also, in the NHDR:
- Compared with Whites, all racial and ethnic groups were more likely to report poor communication with nurses.
- Blacks, American Indians and Alaska Natives, and patients of more than one race also were more likely than Whites to report poor communication with doctors.
- Patients with less than a high school education and patients who speak a language other than English at home were more likely to report poor communication with nurses and doctors.
Patient and Family Engagement: Enabling Effective Patient Navigation and Management of Care
To effectively navigate the complicated health care system, health care providers need to give patients access to culturally and linguistically appropriate tools to support patient engagement. Culturally and linguistically appropriate services (CLAS) are important components of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnosis and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.
Health literacy is the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions (HHS, 2000). Patients with limited health literacy are more likely to have difficulty understanding instructions and taking medication properly. In addition, communication barriers such as limited English proficiency are associated with lower quality of care and place patients at risk for poor clinical outcomes (Ngo-Metzger, et al., 2007).
About one-third of Americans are not "health literate" (Gazmararian, et al. 2003; Parker, et al., 2003). Individuals with inadequate health literacy incur higher medical costs and are more likely to have an inefficient mix of service use compared with those with adequate health literacy (Howard, et al., 2005). They may experience many difficulties, including:
- Less frequent preventive care (Scott, et al., 2002).
- Poorer understanding of their conditions and care (Williams, Baker, Honig, et al., 1998; Williams, Baker, Parker, et al., 1998; Gazmararian, et al., 2003).
- Higher use of emergency and inpatient services and higher rates of rehospitalization (Baker, et al., 1998; Baker, et al., 2002).
- Lower adherence to medication schedules (Baker, et al., 1998).
- Less participation in medical decisionmaking (Berkman, et al., 2004).
Providers Asking Patients To Assist in Making Treatment Decisions
The increasing prevalence of chronic diseases has placed more responsibility on patients, since conditions such as diabetes and hypertension require self-management. Patients need to be provided with information that allows them to make educated decisions and feel engaged in their treatment. Treatment plans also need to incorporate their values and preferences.
Figure 5.4. Adults with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions, by age and insurance status, 2008
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008.
Note: For this measure, lower rates are better.
- In 2008, patients under age 65 who were uninsured and those who had public insurance only were significantly more likely than patients with private health insurance to have a usual source of care who did not ask for their help in making treatment decisions (18.1% and 17.5%, respectively, compared with 14.8%; Figure 5.4).
- In 2008, patients age 65 and over with Medicare and public insurance were significantly more likely than patients with Medicare and private insurance to have a usual source of care not ask for their help in making treatment decisions (25.4% compared with 15.5%).
- In 2008, there were no statistically significant differences between patients of various age groups in the likelihood of their usual source of care asking for their help in making treatment decisions.
Also, in the NHDR:
- In 2008, non-Hispanic White patients were significantly less likely than Hispanics to have a usual source of care who sometimes or never asks for the patient's help to make treatment decisions.
Berkman, N, DeWalt D, Pignone M. Literacy and health outcomes. Summary. Evidence Report/Technology Assessment No. 87. Rockville, MD: Agency for Healthcare Research and Quality; 2004. AHRQ Publication No. 04-E007-1.
Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med 2007;22 Suppl 2:324-30.
U.S. Department of Health and Human Services, Office for Civil Rights. Guidance to federal financial assistance recipients regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. 68 Fed. Reg. 47311-02; August 2, 2008. Available at: http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/factsheetguidanceforlep.html. Accessed April 24, 2009.
U.S. Department of Health and Human Services, Office of Minority Health. Think cultural health: bridging the health care gap through cultural competency continuing education programs. Available at: http://www.thinkculturalhealth.hhs.gov. Accessed August 11, 2011.
Williams MV, Baker DW, Parker RM, et al. Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998 Jan 26;158(2):166-72.
i. For example, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, may require the practitioner or hospital to provide language interpreters and translate vital documents for limited-English-proficient persons. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, may require the practitioner or hospital to provide sign language interpreters, materials in Braille, and/or accessible electronic formats for individuals with disabilities.
ii. This online program (available at http://www.thinkculturalhealth.org ) is accredited for Continuing Medical Education credits for physicians and Continuing Education Units for nurses and pharmacists.
iii. This online program (available at http://www.hrsa.gov/publichealth/healthliteracy/) is accredited for Continuing Medical Education credits for physicians and Continuing Education Units for nurses, physician assistants, pharmacists, and Certified Health Education Specialists.
iv This course (available in the Association of American Medical Colleges' MedEdPORTAL, https://www.mededportal.org/publication/7740 ) has been presented at five national medical schools. For the 2011-2012 academic year, "Stopping Discrimination Before It Starts" has been incorporated into the fourth year curriculum at Emory University School of Medicine and the University of Colorado School of Medicine.
v Available at http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf.