Patient-Physician Communication:Impact on Clinical Outcomes

Meds 1 January 29, 2004

Moira Stewart, Ph.D.Moira Stewart, Ph.D.

Department of Family MedicineDepartment of Family Medicine

Canada Research Chair in Primary Health CareCanada Research Chair in Primary Health Care

Objectives

1. to reinforce your learnings on research methods

2. to learn about the results of a research program on patient-centred communication

Tie to Meds 1 Curriculum

1. follow-up to your Community Health lectures on research methods last fall

2. the results have implications for your evidence-based clinical practice from Year 3 on

Outline of the 3 hour session today

Hour 1 Lecture on Evidence for Patient-Physician Communication 25 min

Small Group Discussion on what are the effective components 20 min

Break 15 min

Outline continued

Hour 2 Mini-lecture on how to evaluate cohort designs 5 min

Lecture on A Study of the "Impact of Patient-Centred Communication on Patient Outcomes in Family Practice” - a cohort study 20 min

Small group discussion- design your own cohort study 20 min

Break 15 min

Outline continued

Hour 3 Mini-lecture on how to evaluate clinical trial designs 5 min

Lecture on A Study “InnovativeTraining to Improve PhysicianCommunication with Breast Cancer Patients: Results of a Randomized Controlled Trial” 15 min

Small group discussion- design your own clinical trial study 15 min

Closing - a synthesis and summary oftake-home messages with examples of exam questions 15 min

Hour 1 Lecture on Evidence for Patient-Physician Communication 25 min

Small Group Discussion on what are the effective components 20 min

Break 15 min

Study Designs

Randomized controlled trials (level I)

Controlled trials without randomizaton (level II - 1)

Cohort or case-control studies (level II - 2)

Comparisons between times or places (level II - 3)

Opinions, descriptive studies (level III)

CTF Recommendation GradesA. Good evidence to recommend

B. Fair evidence to recommend

C. Conflicting evidence, does not allow for a clear recommendation and other factors may influence decision-making

D. Fair evidence to recommend against

E. Good evidence to recommend against

I. Insufficient evidence (quantity and/or quality) tomake a recommendation

Clinical Significance

versus

Statistical Significance

Does Patient-Physician Communication Matter?

Moira Stewart, Ph.D.

ABMS-ACGME ConferenceABMS-ACGME Conference onon

Assessment of Physician-Patient Assessment of Physician-Patient CommunicationCommunication

March 22, 2002March 22, 2002

Synthesis of Evidence

What kind of evidence matters?

A - evidence Results with clinical significance

Does the evidence on patient-physician communication measure up to these standards?

YES

The evidence includes

Randomized controlled trials

Clinically significant results on important outcomes

PHYSICIAN OUTCOMES

PATIENT OUTCOMES

PHYSICIAN OUTCOMES

Malpractice claims

Time

Physician satisfaction

PATIENT OUTCOMES

Satisfaction

Adherence

Health

Stewart. Effective Physician-Patient Communication and Health Outcomes: A Review. Canadian Medical Association Journal. 1995;152(9):1423-1433

Stewart, Brown, Boon et al. Evidence on Patient-Doctor Communication, Cancer Prevention and Control, 1999;3:25-30

Brown, Stewart & Ryan. Outcomes of Patient-Provider Interaction, Handbook of Health Communication, Clinics in Geriatric Med, 2000;16:25-36

PHYSICIAN OUTCOMES

Malpractice claimsMalpractice claims Time

Physician satisfaction

Malpractice Claims

8 studies

RCTs and other designs

Malpractice Claims

Important differences

eg. Hickson et al., 1994

% PoorPatient-PhysicianCommunication

No claims 8.2

All others 17.7

High frequency 27.6

High pay 24.7

Malpractice Claims

1) time: feeling rushed, short visit

2) explanation: inadequate/minimal information, fewer orienting statements

3) connection: feeling ignored, no acknowledgement of patient statements, no reflection of affect, no eye contact, no friendly physical contact, no humour

4) facilitation: not understanding patient and family perspectives, no eliciting patients’ opinions and cues

5) support: devaluing patient and family views, harsh critical tones

Physician Outcomes

Malpractice claims

TimeTime Physician satisfaction

Time

19 studies

RCTs and other designs

Time 6 studies found no differences in time

but communication was increased in terms of

exploration of psychosocial issues

collaboration with patients

exploring patients’ ideas and concerns

patient volume of communication

patient-centred communication

Time

10 studies found differences in visits of longer duration in terms of

more counselling

more prevention (e.g. vaccination)

larger proportion of patient needs recognised

higher patient satisfaction

more follow-up

better guideline implementation

family practice average 10 minutes

primary care internal medicine average 21 minutes

Time

Time

In the situation of limited time, patient satisfaction is related to:

• a brief period of time to "chat" about non medical topics

• providing patients with feedback on clinical findings

Physician Outcomes

Malpractice claims

Time

Physician satisfactionPhysician satisfaction

Physician Satisfaction

one study

cohort study

Physician Satisfaction

Important difference in physician satisfaction when the communication was rated as participatory

(Roter et al., 1997)

PHYSICIAN OUTCOMES

Malpractice claims

Time

Physician satisfaction

PATIENT OUTCOMES

Satisfaction

Adherence

Health

PATIENT OUTCOMES

SatisfactionSatisfaction Adherence

Health

Satisfaction

many studies, none were RCTs

3 key review papers

Satisfaction

Consistent and important effects of communication on patient satisfaction

Satisfaction

1) Warmth/caring

2) Medical competence

3) Balanced communication of both psychosocial and biomedical concerns

4) Continuity of relationship

5) Expression of patient expectations

PATIENT OUTCOMES

Satisfaction

AdherenceAdherence Health

Adherence

16 studies and review papers

No RCTs

Adherence

Communication is the most important determinant of patient adherence

e.g. Stewart, 1984

PhysicianPatient-Centered

% Adherence

Low 55.4

High 73.1

Adherence

1) information exchange and patient education

2) finding common ground regarding expectations

3) active role for the patient

4) positive affect, empathy and encouragement

PATIENT OUTCOMES

Satisfaction

Adherence

HealthHealth

Health Outcomes

23 studies

12 RCTs: 11 demonstrated significant effects

Health Outcomes

(Kaplan & Greenfield, 1989)

Important effects

e.g. BP (diastolic)

Experimental Control

Pre 95 93

Post 83 91

Health Outcomes Important effects

e.g. Pain (Egbert et al., 1964)

Experimental Control

Severity of Pain 1.2 1.7

1

Health Outcomes Affected

Patient anxiety Psychologic Distress Symptom Resolution Functional Status Self-reported Health Status Physiologic status e.g.

HA1

BP

“If a new drug was shown to be as effective in rigorous

studies as patient-physician communication is, the

industry would aggressively market that drug!”

Health Outcomes

Physician during history taking

asks many questions about patient’s ideas and expectations

asks about patient’s feelings

shows support

Health Outcomes

Physician during discussion of the management plan

encourages patient to ask questions and get information

provides information packages

provides emotional support

willing to share decisions

physician and patient agree on the nature of the problem and the follow-up

PATIENT OUTCOMES

Satisfaction

Adherence

Health

Does Patient-Physician Communication Matter?

Yes - to the physician

Yes - to the patient

Evidence-based guidelines for patient-physician communication

Clear information provided to the patient

Asks about patient ideas, expectations and feelings

Mutually agreed upon goals

An active role for the patient

Positive affect, empathy, and support from the physician

Hour 1 - Small Group Discussion

a) quality of the evidence presented

b) effective communication components

Hour 2 Mini-lecture on how to evaluate cohort designs 5 min

Lecture on A Study of the "Impact of Patient-Centred Communication on Patient Outcomes in Family Practice” - a cohort study 20 min

Small group discussion- design your own cohort study 20 min

Break 15 min

Categories of Research Design Observational or experimental

In an observational study the researcher collects

information but does not influence events(Level II - 2)

By contrast, in an experimental study the researcher

deliberately influences events (Level I)

Observational studies

cohort design

case-control study

cross-sectional study

Cohort study

Selection of subjects

Loss to follow-up

Other problems

Long-term studies may sufferfrom problems associated with

changes and over time

Surveillance bias

THE IMPACT OF PATIENT-CENTRED CARE ON PATIENT

OUTCOMES IN FAMILY PRACTICE

Grant #04106

Health Services Research, Ministry of Health of Ontario

Investigators:Moira Stewart, Ph.D.

Judith Belle Brown, Ph.D.Allan Donner, Ph.D.

Ian R. McWhinney, M.D.Julian Oates, M.D.

Wayne Weston, M.D.

That adult patients whose first visit in an episode of illness is patient-centred will more frequently demonstrate recovery from the discomfort of the symptom after two months (and recovery from the concern about the symptom) and will experience less subsequent medical care (i.e. fewer patient-initiated visits, fewer tests and referrals) in the two months of study.

HYPOTHESIS

PATIENT-CENTRED MEASURES

Measures of Patient-centred communication based on analysis of audiotapes (continuous)

Patient perception of patient-centredness total score (continuous)

PATIENT-CENTRED MEASURES

Patient perception, subscore that the illness experience had been explored (continuous)

Patient perception, subscore that the patient and doctor found common ground (continuous)

PATIENT HEALTH OUTCOMES

Patients’ level of discomfort, post-encounter and two months later (continuous)

Patients’ level of concern, post-encounter and two months later (continuous)

PATIENT HEALTH OUTCOMES

Medical Outcomes Study (MOS) variables assessed two months after the study visit:

physical health (continuous) mental health (continuous) perceptions of health (continuous) social health (continuous) pain (continuous) role function (dichotomous)

MEDICAL CARE OUTCOMES

Lab tests ordered during the two months (dichotomous)

Referrals during the two months (dichotomous)

Number of visits during the two months after the study visit (continuous)

ANALYSIS confounding variables assessed; confounding variables included; multiple regression for continuous

outcomes adjusting for practice using PROC MIXED

multiple logistic regression for dichotomous outcomes adjusting for practice using PROC LOGISTIC and PROC IML

RESULTS

random sample of physicians 52% refusal rate participants were:

– same year of graduation and location of practice

– more likely to be CCFP n = 39

RESULTS

28% patient refusal rate participants were:

– same age as all eligibles

– more likely to be male than all eligibles

n = 315

DEMOGRAPHIC CHARACTERISTICSOF THE PATIENTS

54% female 40% > 45 years of age 60% married 42% had some post-secondary education

Outcome - Patients’ Level of Discomfort

B Estimate SE p

Independent Variables:

Total Patient Perception Score 6.04 2.70 0.03

Baseline level of discomfort 0.84 0.037 0.0001

Patients’ main presenting problem

–Musculoskeletal 2.42 3.39 0.48

–Respiratory 6.56 3.25 0.04

–Other 2.42 3.24 0.46

–Digestive 6.18 4.07 0.13

Patients’ marital status 0.63 2.03 0.76

Multiple Regression of Perception Scores in Relation to Patients’ Discomfort

n = 297

Mean Level of Discomfort by Quartiles of the Total Patient Perception Score

Mean Level of Discomfort

Perceptions: x

First quartile - perception that the visit was patient-centred 42.5

Second quartile 45.0Third quartile 45.2Fourth quartile - perception that the

visit was not patient-centred 48.8

Proportion Receiving Diagnostic Tests by Quartiles of the Score on Patient Perception of Patient Centredness

Proportion Receiving

Perceptions: Diagnostic Tests

First quartile - perception of finding common ground 14.6%

Second quartile 17.0%Third quartile 19.5%Fourth quartile - perception of not finding

common ground 24.3%

Proportion Referred by Quartiles on Patients’ Perception of Patient Centredness

Proportion Perceptions: Referred

First quartile 7.9% - perception of finding common ground Second quartile 4.3%Third quartile 6.9%Fourth quartile 16.2% - perception of not finding common ground

Measure of Patient-Centred Communication

OUTCOMES Measure of patient-centredcommunication

Patient perceptionof patient-centredness

Patients’ level of discomfort NS S

Patients’ level of concern NS NS

SF-36 NS S

Diagnostic tests NS S

Referrals NS S

Number of subsequent visits NS NS

Relationships Among Measure of Patient-Centred Communication, Patient Perceptions of Patient-Centredness, and Outcomes

Measure of Patient-Centred Communication

N.S.

N.S. Significant p=.01Health and Medical Care Outcomes

Patient Perception that doctor explored the illness experience

Patient perception that the doctor and patient found common ground

N.S.

Significant p<.05

Surprising ResultThe communication score (what we think is good communication) was not related to outcomes.

BUTThe patients’ perception (what the patients noticed) was related to outcomes.

Conclusion

Only when physicians’ level of patient-centredness reaches a level that patients notice, outcomes are affected.

Hour 2 - Small Group Discussion

Design your own cohort study on the topic

Hour 3 Mini-lecture on how to evaluate clinical trial designs 5 min

Lecture on A Study “InnovativeTraining to Improve PhysicianCommunication with Breast Cancer Patients: Results of a Randomized Controlled Trial” 15 min

Small group discussion- design your own clinical trial study 15 min

Closing - a synthesis and summary oftake-home messages with examples of exam questions 15 min

Intervention Studies - Validity Was the assignment of patients to

treatment/placebo randomized?

true randomization

pseudo-randomization or deterministic method of allocation

treatment/placebo allocation

Were all patients properly accounted for and attributed at its conclusion?

completeness of follow-up

intention to treat analysis

Intervention Studies - Validity

Were patients, clinicians and study personnel “blind” to intervention?

double blinding

methods used to ensure blindness

creative ways to “unblind” a study

Intervention Studies - Validity

Were groups similar at the start of the trial?

carefully consider all importantbaseline characteristics of both groups

post-hoc analysis accounting for differences in the groups

Intervention Studies - Validity

Aside from the experimental interventions, were the groupstreated equally?

co-interventions

How large was the treatment effect?

Intervention Studies - Validity

Innovative Training to Improve Physician Communication With

Breast Cancer Patients: Results of a Randomized Controlled Trial

Principal Investigator: Moira Stewart, Ph.D.

Funded by:

Canadian Breast Cancer Research Initiative &

National Cancer Institute of Canada

Breast Cancer Survivors: Louisette Smith

Brenda McKelvey-Donner

Research Expertise: Judith Belle Brown, Ph.D.

Carol McWilliam, M.Sc.N., Ed.D.

Allan Donner, Ph.D.

Clinical Expertise: Ron Holliday, M.D.

Ken Leslie, M.D.

Tim Whelan, M.D.

Alan Gavin, M.S.W.

Irene Cohen, M.D.

Marjorie Wood, MB,ChB

Praful Chandarana, MB,ChB

Education Expertise: Wayne Weston, M.D.

Tom Freeman, M.D.

Susan McNair, M.D.

Consultants: Ian R. McWhinney, M.D.

Jack Laidlaw, M.D.

Don Cowan, M.D.

Project Coordinator: Joanne Galajda

Research Assistant: Jo-Anne Aubut

Co-Chairs: Louisette Smith Registered Nurse

Brenda McKelvey-Donner Vice-Principal

Members: Sharron Bearfoot R.N. at Coronary Care Unit

Barb Barton-McMillan Social Worker

Anne Buchanan Volunteer, Canadian Cancer Society

Katherine DeCaluwe Hair Stylist

Barbara Garvin Regional Manager, London Canadian

Cancer Society

Addie Gushue Medical Claims Assessor for the

Ministry of Health

Sandy Krueger Independent Business Woman

Margie McPhillips Homemaker

Breast Cancer Advisory Group

Does intensive training improve

physician communication with

breast cancer patients?

To design an education program for physicians based on real life experiences of breast cancer survivors, with the goal of improving physicians’ communication

To evaluate the program

Purpose of the Study

3. Evaluate the education program in a randomized controlled trial

3 Phases of Study

1. Qualitative Study

2. Pre-test education program

Relationship-building

Information Sharing

Creating the Experience of Control

Mastering the Whole Person

Qualitative Study Findings

•Introduction•Physician’s Perspective•Patient’s Perspective - Video•Patient’s Perspective - Discussion With Breast Cancer Survivors•Video Demonstration•Lunch•Videotaped Standardized Patient Interviews (2)•Video Feedback•Evaluation of the Course

Overview of the 6 Hour CMEPatient-Physician Communication

6 hour education

Phase 3 - Randomized Controlled TrialRecruitment - 51 family physicians, surgeons, oncologists

Randomization

2 hour education

2 standardized patient appointments

2 standardized patient appointments

2 standardized patient appointments

2 standardized patient appointments

10 patient questionnaires

10 patient questionnaires

Oncologists & Surgeons Only

Outcome Measures

1. Audiotaped standardized patients in office setting

2. Patient questionnaires

Mastering the Whole Person Experience:

9. Eliciting & Validating Issues of the Person

Measuring CommunicationBuilding Relationships: 1. Eliciting & Validating Feelings

2. Eliciting & Validating Ideas

3. Offering Support

Sharing Information: 4. Opportunity to Ask Questions

5. Mutually Discussing the Problem & Management Plan

6. Clarification of Agreement

Creating the Experience of Control:

7. Eliciting & Validating Expectations

8. Eliciting & Validating Impact on Function

RESULTS

p-value

Oncologists: N.S.

Surgeons: N.S.

Family Physicians:

Eliciting & Validating Issues of the Person .02

(Validating Issues of the Person) .05

Offering Support .02

Physician Communication Scores from Audiotaped Office Visits(6 hour vs. 2 hour education)

Pre Post

6 hour education

(n = 8) 72.0 82.8

2 hour education

(n = 9) 60.1 58.7

Multiple regression:

* (p=.02) Statistically significant difference between the 6 hour education and the 2 hour education at post-intervention controlling for pre-intervention scores

Family Physicians

Eliciting and Validating Issues of The Person*

Perceptions of patient-centredcommunication N.S.

Satisfaction with Dr.’s information-giving & interpersonal skills .03

Psychological distress N.S.

Feel better after visit with Dr. .02

Differences in patient outcomes between oncologists and surgeons who had 6 hr. education vs. those who had 2 hr. education:

Patient Outcomes

6 hour education 88.2%(n = 51)

2 hour education 70.6%(n = 51)

Logistic Regression

* (p=.02) Statistically significant difference between the patients whose doctor was in the intervention group vs. the control group at post-intervention controlling for patient’s education and number of medical conditions

Patient Feeling BetterAfter Visit With Doctor*

Patients of oncologists & surgeons had greater satisfaction & felt better after visit

Conclusions About Effectiveness of the 6 Hour Education

Family physicians improved communication (audiotapes)

Hour 3 - Small Group Discussion

Design your own randomized controlled trial on the topic.

Take-home messages

– there is an evidence-base for patient-centred communication

– there are 5 key communication elements revealed by the literature

– cohort studies have a role in explaining the impact of patient-centred communication

– the cohort study revealed a pathway

– communication of practising physicians and surgeons can be improved through CME

– the RCT revealed an effect on behaviour and patient perceptions

Take-home messages

– Lessons from research need to take account of quality of study design (Level I-III and A to E)

– Lessons also need to take account of clinical significance as well as statistical significance

– There were 6 criteria presented to evaluate the quality of cohort studies

– There were 6 criteria presented to evaluate the quality of the RCT

Sample examination questions1. Which is a correct label for a Level of Study Design?

a) 100%

b) II - 1

c) 3 - 6

d) B

2. Which is a correct label for a Recommendation for the Evidence created by the Canadian Task Force on Preventive Health Care?

a) 2

b) A

c) 80%

d) III

Sample examination questions

3. Clinical significance means the chances the study results could have occurred by chance alone.

a) True

b) False

4. How many communication elements does the literature reveal to affect outcomes?

a) too many to learn

b) 75

c) two

d) five

Sample examination questions

5. Which is a key criterion to evaluate a cohort study?

a) measure the outcome first

b) measure the factor before the outcome

c) be sure the patients are “blind” to the intervention

d) be sure the subjects were selected over a long period of time

6. What is the key criterion to evaluate an RCT?

a) follow patients over time

b) lose patients to follow-up

c) measure the outcome first

d) the assignment of participants is randomized