Article Figures & Data
Figures
- Figure 1
Patients’ desire for involvement in management decision making.
Tables
Characteristic Deprivation Area P Value Low High Age in y, mean (SD) 50.50 (19.13) 51.45 (17.07) .60 Female, No. (%) 199 (66.3) 223 (62.6) .50 Married/living with partner, No. (%) 174 (58.6) 140 (39.8) <.001 Chronic conditions, No. (SD) 1.6 (1.4) 2.2 (1.9) <.001 ≥3 Chronic conditions, No. (%) 68 (22.4) 131 (36.8) <.001 Disabled by condition, No. (%) 102 (34.1) 182 (51.7) <.001 Good or better rating of health, No. (%) 185 (62.3) 142 (40.5) <.001 Anxiety score, mean (SD)a 10.82 (3.00) 11.59 (3.32) .003 Depression score, mean (SD)a 5.46 (5.45) 7.28 (6.59) <.001 ≥2 Problems to discuss, No. (%) 129 (42.9) 192 (54.1) .01 Desire for involvement in decision making, mean (SD)a 2.43 (0.61) 2.05 (0.65) <.001 Note: P values for differences between areas of deprivation are extracted from multi-level linear or logistic regression models that include fixed effects for age and sex and a random effect for GP level.
↵a Possible anxiety scores ranged from 6 to 24 (higher meaning worse anxiety), depression scores from 0 to 27 (higher meaning worse depression), and desire for involvement from 1 to 5 (where 1 means doctor alone should decide and 5 means patient alone should decide).
Variable Level of Deprivation Effect Size (Cohen’s d) P Value Low Mean (SD) High Mean (SD) GP verbal communication Patient-centered score total 1.42 (0.45) 1.27 (0.49) 0.319 .02 Component 1: Exploring both disease and illness experience 0.28 (0.13) 0.25 (0.13) 0.231 .08 Component 3: Understanding of the whole person 0.34 (0.38) 0.29 (0.38) 0.132 .22 Component 3: Finding common ground 0.81 (0.14) 0.72 (0.18) 0.559 <.001 GP nonverbal communication Smiles 0.38 (.65) 0.29 (0.58) 0.146 .20 Supportive facial expressions 1.78 (1.76) 1.27 (1.41) 0.357 .04 GP Head nods 6.05 (5.53) 4.05 (5.88) 0.350 .08 GP seconds looking at patient 21.51 (9.10) 17.94 (10.23) 0.369 .01 GP seconds looking at computer 6.18 (8.81) 9.63 (10.62) −0.353 .02 Consultation length and continuity Length of consultation (minutes) 9.24 (4.17) 9.17 (4.11) 0.017 .90 How well patient knows GP 3.48 (1.29) 4.04 (1.03) −0.085 .001 Empathy and enablement Patients’ score of GP empathy (CARE Measure) 4.50 (0.62) 4.34 (0.66) 0.250 .02 Patient enablement (PEI) 4.62 (3.29) 4.28 (3.45) 0.101 .20 CARE = consultation and relational empathy; GP = general practitioner; PEI = patient enablement instrument.
Note: P values for differences between areas of deprivation are extracted from multi-level linear regression models that include fixed effects for age and sex and a random effect for GP level.
Variable Level of Deprivation Effect Size (Cohen’s d) P Value Low Mean (SD) High Mean (SD) MYMOP symptom scorea Baseline 4.58 (1.50)
n = 2664.90 (1.56)
n = 310−0.209 .01 1 Month after baseline 2.79 (1.78)
n = 2213.48 (2.01)
n = 211−0.363 <.001 Change from baseline −1.76 (2.10)
n = 200−1.21 (2.13)
n = 188−0.260 .01 MYMOP well-being scorea Baseline 3.29 (1.63)
n = 2873.74 (1.78)
n = 340−0.264 .005 1 Month after baseline 2.78 (1.62)
n = 2253.53 (1.91)
n = 211−0.424 <.001 Change from baseline −0.49 (1.90)
n = 217−0.20 (2.09)
n = 203−0.145 .15 GP = general practitioner; MYMOP = Measure Yourself Medical Outcome Profile.
↵a MYMOP scores are generated by the patient on a 7 point scale from 0 (“as good as it could be”) to 6 (“as bad as it could be”). Thus high mean scores at baseline or follow-up reflect worse symptoms and well-being. Change scores are calculated as score at 1 month minus score at baseline.
Note: P values for differences between areas of deprivation are extracted from multi-level linear regression models that include fixed effects for age and sex and a random effect for GP level.
Covariate (n) Adjusted Parameter Estimate Value (95% CI) P Value Predictors of MYMOP symptom scores at 1 month Baseline MYMOP score (388) −0.71 (−0.83 to −0.59) <.001 High deprivation level (432) 0.16 (−0.24 to 0.56) .43 10-y Increase in age (430) −0.03 (−0.14 to .08) .61 Male sex (430) −0.08 (−0.49 to .31) .68 Multiple morbidity count (432) .13 (0.01 to 0.26) .03 Rating of health (423) .25 (0.02 to 0.47) .03 GP Visits in past year (401) .05 (0.01 to 0.08) .01 Duration of symptoms >4 wk (378) .53 (0.15 to 0.92) .006 PHQ-9 Baseline score (417) .05 (0.02 to 0.09) .003 Minutes spent with GP (423) .06 (0.02 to 0.11) .008 CARE Measure score (432) −0.40 (−0.70 to −0.10) .01 Predictors of MYMOP well-being scores at 1 month Baseline MYMOP score (420) −0.83 (−0.94 to −0.72) <.001 High deprivation (436) 0.24 (−0.11 to 0.59) .18 10-y Increase in age (434) −0.01 (−0.11 to 0.09) .80 Male sex (434) −0.18 (−0.53 to 0.17) .31 Rating of health (428) 0.38 (0.19 to 0.58) <.001 Duration of symptoms >4 wk (376) 0.42 (0.09 to 0.75) .01 GP visits in past year (406) 0.04 (0.01 to 0.07) .01 PHQ-9 baseline score (421) 0.06 (0.03 to 0.09) <.001 CARE measure score (436) −0.27 (−0.53 to −0.02) .04 CARE = consultation and relational empathy; GP = general practitioner; PHQ-9 = patient health questionnaire.
Note: For both outcome measures, the baseline MYMOP score, age, sex, and deprivation level were included in the adjusted regardless of significance. The full unadjusted and adjusted results are shown in the Supplemental Appendix, available at http://annfammed.org/content/14/2/117/suppl/DC1. A negative score in the parameter estimate (eg, baseline MYMOP scores) indicates a positive effect of that variable on outcomes at 1 month (because higher MYMOP scores represent worse symptoms and worse well-being). Depending on the nature of the covariate measured, the parameter estimate can be interpreted as the mean difference in the outcome variable associated with a 10-year increase in age, a 1-point increase in other continuous or ordinal predictors, or being in the specified subgroup (compared with the other) for binary predictors.
Supplemental Appendixes
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The Article in Brief
General Practitioners' Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation
Stewart W. Mercer , and colleagues
Background Primary care has the potential to help reduce health inequalities but there has been little research on patients' expectations and the characteristics of doctor visits in differing socioeconomic areas. This study compares general practitioner visits in areas of high and low deprivation in Scotland and analyzes factors that predict poorer or better outcomes in both low and high socioeconomic groups.
What This Study Found Compared with affluent areas, patients in deprived areas have higher rates of ill health, psychosocial problems, and multimorbidity; more problems to discuss within the same visit time yet less desire for shared decision making; perceive their GPs as less empathetic; and have worse outcomes at one month. Physicians in deprived areas display verbal and nonverbal behaviors that are less patient-centered. Perceived physician empathy is the only visit factor that predicts better outcomes in patient symptoms and wellbeing in both high- and low-deprivation groups.
Implications
- To improve health in deprived areas, the authors call for policies that address wider social determinants of health and improve consultation quality.
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