Patient-Centered Clinical Consultations Show Mixed Results

Ricki Lewis, PhD

December 21, 2012

An update to a long-term assessment of the outcomes of patient-centered clinical consultations indicates direct positive effects on patient encounters and mixed results for patient satisfaction, health behavior change, and health status, according to a systematic review published online December 12 in the Cochrane Library.

Patient-centered care (PCC) is a philosophy that emphasizes the whole patient and not just the part of the body affected in a disease. PCC addresses patients' concerns and beliefs about their medical problems and presents treatment options, thereby enabling clinicians to show empathy and allowing patients to recognize that empathy. In PCC, the patient shares control of the consultation and assists in decision-making.

Francesca Dwamena, MD, from the Department of Medicine, Michigan State University College of Human Medicine, East Lansing, and colleagues searched databases for randomized controlled trials conducted from January 2000 until June 2010 that evaluated interventions designed to promoting PCC. They identified 43 randomized controlled trials that fit their criteria. Most of the studies targeted primary care physicians or community or hospital-outpatient based nurses, but a few trials were aimed at specialists (oncologists and obstetrician-gynecologists). Most of the patients considered were adults with general medical problems, except for 2 studies that included children with asthma and 3 that used simulated patients.

The researchers evaluated the types of interventions (providers only or patients and providers; use of educational materials about the diagnosed disease) and analyzed 4 outcomes: direct effects on patient encounters (consultation process variables; 29 studies); patient satisfaction (11 studies); health behavior change, such as agreeing to a care plan and follow-up (7 studies); and health status, such as physiological measures and clinical assessment (10 studies).

For the 4 studies that measured consultation skills or behaviors using dichotomous variables, Dr. Dwamena and colleagues saw no effect (relative risk [RR], 0.96; 95% confidence interval [CI], 0.82 - 1.13). However, they saw a statistically significant benefit from the intervention in the 12 studies using continuous variables (standard mean difference [SMD], 0.70, 95% CI, 0.57 - 0.82).

For patient satisfaction, the 4 studies that used dichotomous measures showed an insignificant trend for benefit (RR, 0.99; 95% CI, 0.93 - 1.06), whereas the 7 studies that used continuous measure showed a significant improvement with the intervention (SMD, 0.35; 95% CI, 0.20 - 0.49).

For healthcare behavior, the 4 studies with dichotomous endpoints favored intervention (RR, 1.28; 95% CI, 1.18 - 1.38), whereas the 3 studies with continuous endpoints did not (SMD, −0.04; 95% CI, −0.28 to 0.20).

For health status, trials showed an improvement with the intervention, regardless of the type of endpoint used. Five studies with dichotomous outcomes (RR, 1.36; 95% CI, 1.01 - 1.83) and 5 studies with continuous outcomes (SMD, −0.25; 95% CI, −0.36 to −0.15) favored intervention.

"Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed," the researchers conclude.

The investigators also discovered that even minimal (<10 hours) training helped providers share control in the consultation process and decision-making. In addition, the use of educational materials improved health behavior and patient satisfaction and consultation processes, but had mixed results for health status.

Limits of the analysis include the assessment of several diverse outcomes and the use of single-item consultation and health behavior measures.

The newly published review is an update of a 2010 review by the same group.

One coauthor is an editor at Cochrane Consumers and Communications Review Group. The other authors have disclosed no relevant financial relationships.

Cochrane Library. Published online December 12, 2012. Abstract

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