Patient-centered Care is Associated with Decreased Health Care Utilization

Klea D. Bertakis, MD, MPH; Rahman Azari, PhD

Disclosures

J Am Board Fam Med. 2011;24(3):229-39. 

In This Article

Abstract and Introduction

Abstract

Purpose: This article uses an interactional analysis instrument to characterize patient-centered care in the primary care setting and to examine its relationship with health care utilization.
Methods: Five hundred nine 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 their use of medical services and related charges monitored over 1 year.
Results: Controlling for patient sex, age, education, income, self-reported health status, and health risk behaviors (obesity, alcohol abuse, and smoking), a higher average amount of patient-centered care recorded in visits throughout the 1-year study period was related to a significantly decreased annual number of visits for specialty care (P = .0209), less frequent hospitalizations (P = .0033), and fewer laboratory and diagnostic tests (P = .0027). Total medical charges for the 1-year study were also significantly reduced (P = .0002), as were charges for specialty care clinic visits (P = .0005), for all patients who had a greater average amount of patient-centered visits during that same time period. For female patients, the regression equation predicted 15.47% of the variation in total annual medical charges compared with male patients, for whom 31.18% of the variation was explained by the average percent of patient-centered care, controlling for sociodemographic variables, health status, and health risk behaviors.
Conclusions: Patient-centered care was associated with decreased utilization of health care services and lower total annual charges. Reduced annual medical care charges may be an important outcome of medical visits that are patient-centered.

Introduction

Over the years, an extensive body of literature has described and advocated for a patient-centered approach to medical care.[1–12] In its 2001 report, "Crossing the Quality Chasm: A New Health System for the 21st Century,"[5] the Institute of Medicine presented an action plan for reinventing the health system to improve our nation's health. One of the 6 key components in achieving quality health care was identified as "patient-centeredness."[5] Though there is no uniform definition of patient-centered communication, several scales have been developed to measure it.[6] It would seem that patient-centered care is a multifaceted construct, and instruments designed to measure it have varying levels of reliability and relatively low concurrent validity. Nonetheless, these instruments generally measure the following communication behaviors: eliciting understanding and validating the patient's perspective; understanding the patient within his or her psychosocial context; reaching a shared understanding with the patient of the problem and its treatment; and creating a partnership in which "activated" patients share in decision making, power, and responsibility.[4]

Health care organizations are being challenged to provide quality medical care while managing costs. A patient-centered approach is increasingly being considered a paradigm for high-quality interpersonal care. There is still a lack of consistent research evidence linking patient-centered care to improved patient outcomes,[8,13–17] but it has been demonstrated that a practice style emphasizing patient activation is associated with significantly lower primary care charges.[18] Moreover, there is emerging evidence for an association between patient-centered communication and the utilization of medical resources. It has been found that patients who perceived their visit as having been patient-centered received fewer diagnostic tests and referrals.[14] Others have reported that physicians who have visits characterized by the greatest amount of patient-centered communication also have the lowest expenses for diagnostic testing.[19] In a recent study examining the determinants and outcomes of patient-centered care using an established interactional analysis instrument modified to characterize a patient-centered physician practice style, evidence was found to suggest that a patient-centered approach to primary care was associated with lower annual medical charges.[20]

A possible explanation for the relationship between patient-centered care and decreased health care utilization may be that patients experience decreased anxiety and increased trust in their physicians when they actively participate in their own care and feel that their physicians understand their symptoms.[14,21] Physicians, in turn, may gain more information about the patient's concerns and questions while engaging in patient-centered communication.[22] These patient and physician factors may all contribute to a decreased need for further diagnostics and consultations.

The object of the present study was to determine the amount of patient-centered care given to patients in a primary care setting over the course of 1 year and to relate this to the utilization of medical services and subsequent charges in 5 categories: (1) primary care clinic visits, (2) specialty care clinic visits, (3) emergency department visits, (4) hospitalizations, and (5) diagnostic services (laboratory, diagnostic, and radiologic tests). We sought to contribute to the findings of other studies investigating the relationship between patient-centered communications and medical costs by controlling for patient health status and health risk behaviors, in addition to sociodemographic characteristics, because these have been shown to significantly impact health resource use[23,24] and the process of care.[25,26] By studying new patients (rather than a mix of new and established patients), statistically adjusting for health status and health risk behaviors and employing measures used in health services research, we attempted to diminish potential sources of bias and confounding to help clarify the association between a patient-centered approach and the use of health care resources.

Patient sex also impacts the doctor-patient interaction,[27] as has been demonstrated in a number of studies. Female patients ask more questions, get more information, receive more counseling and preventive services, and have more participatory visits than male patients.[28–30] These may be considered elements of patient-centered care. One recent study's findings suggested that, compared with male patients, women have interactions characterized by greater patient-centered communication.[31] Moreover, women have higher medical care service utilization and higher associated charges than men.[32] In consideration of these effects, patient sex was controlled in the analyses, and female and male patients were also analyzed separately in an effort to further explore the association between patient-centered care and medical charges.

Based on the literature and our own preliminary findings, we hypothesized that patient-centered medical care would be associated with decreased utilization of health care resources and subsequent charges.

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