Patient-centredness in chronic illness: what is it and does it matter?

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Abstract

The evidence as to whether patient-centredness is associated with beneficial physical and psychological outcomes is inconsistent. This review of published research on health care communication in chronic illness investigates whether (i) studies of patient-centred consultations use distinctive concepts, (ii) different concepts are differentially associated with health outcomes. Studies of patients with a chronic illness consulting a health professional were included if they measured health professional–patient interaction and a physical or psychological outcome. Thirty studies were identified, falling into two, reliably distinct, categories. In the first, health professionals took the patient’s perspective and in the second, they sought to “activate” the patient. The 10 studies taking the latter approach were more consistently associated with good physical health outcomes than were the 20 studies taking the former approach. The suggestion that different types of patient-centredness have different associations with physical health outcomes should be investigated further in experimental studies.

Introduction

It is now widely recognised that the successful management of chronic illness depends on the active behavioural involvement of the patient [1], [2]. Self-management of chronic illness involves both the adoption of new behaviours (e.g. blood glucose monitoring in diabetes; adherence to medication, etc.) as well as changes in existing behaviours (e.g. dietary modification). Cumulative evidence shows that achieving behaviour change depends on a range of factors, including perceptions of health [3] and illness [4], as well as effective communication with health care professionals (HCPs) [5]. The focus of the present paper is to examine the relationship between the quality of HCP–patient communication and outcome in chronic illness in a review of the evidence.

Broadly, the evidence on HCP communication is that a patient-centred approach has beneficial effects on patient outcomes, particularly in engaging patients more actively in their treatment [6]. However, there are inconsistencies in the way that patient-centredness has been defined (see below) and in the study findings. Thus, the aim of the present review is to attempt to untangle the key factors which might explain discrepancies in the findings. An example of this inconsistency can be seen by comparing the results from two good quality studies, both of which were designed to increase patient-centredness in consultations with patients with chronic health problems. One focused on the empowerment or development of patients’ skills to question and negotiate with the doctor and this resulted in positive health outcomes across a number of clinical groups [7]. The other was a large randomised-controlled trial evaluating an intervention designed to improve the HCP’s ability to elicit diabetic patients’ views [8]. Although this resulted in greater patient satisfaction in the intervention group, it resulted in a poorer level of blood glucose control than in the control group.

The striking difference in the findings from these two studies is puzzling and, in searching for an explanation, we believe that we may have identified an important factor in patient-centredness which, in turn, may help to clarify the concept. There is a great variation in the definitions of patient-centredness used by researchers, which is illustrated in the examples in Table 1 and discernible in recent reviews on this topic, e.g. [9]. A closer examination of the differences between the Kaplan et al. [7] and Kinmonth et al. [8] studies provides an indication of one potential important difference within this variation. Whereas the Kinmonth et al. [8] study was designed to improve the skill of the HCP in eliciting patients’ views, the Kaplan et al. [7] study focused on ensuring that the patient played a more active role in the consultation.

In considering these findings, it has occurred to us that they may be revealing two separable but important ingredients of patient-centredness. These are (i) the ability to elicit and discuss patients’ beliefs and (ii) the ability to activate the patient to take control in the consultation and/or in the management of their illness. Both of these components of patient-centredness may be crucial for producing positive outcomes from a consultation but they may differ in the type of outcome which is affected. Research in this area has focused on a fairly diverse range of outcomes, including patients’ understanding and satisfaction, behavioural factors such as treatment adherence, quality of life and various physical health measures. Kok and Schaalma [10] stress the importance of distinguishing between adherence and self-management for those with chronic illness. They describe the former as “blindly following health recommendations” (p. 747) and the latter as “people in their own environments becoming empowered to make good decisions on the basis of physiological and psychological disease symptoms” (p. 748). Within this framework, we suggest that the first ingredient of patient-centredness, the ability to elicit and discuss patients’ beliefs within the consultation, may be sufficient to promote patient satisfaction. This may increase adherence to advice given within the consultation. The second ingredient, the ability to activate the patient to take control within the consultation, may be necessary to promote more general self-management. Consultations using this may therefore be associated with better health outcomes than those based only on the first ingredient.

In this article, we propose that the two components of patient-centredness identified in the two selected studies represent separable but linked steps in effective health care communication. The first step involves the ability of the HCP to elicit and adopt the patient’s perspective, and the second involves the ability of the HCP to facilitate active engagement of the patient in the management of his or her illness. The primary aim of this review is to evaluate the extent to which it is possible to classify patient-centredness studies into one or other of these two types and to determine whether doing this gives rise to a more consistent pattern of research findings. It is important to add that we do not believe that these separable components are mutually exclusive. Moreover, we believe that the second step is most effective if it takes place within the context of a consultation in which the HCP has elicited and discussed a patient’s beliefs.

Thus the aims of this review are to,

  • (i)

    determine whether studies of patient-centred consultations use reliably distinctive concepts,

  • (ii)

    investigate whether different concepts are differentially associated with health outcomes in chronically ill patients.

Section snippets

Method

A systematic search was conducted of empirical studies published between 1970 and 2000. An emphasis was placed on high recall (sensitivity) at the expense of precision (specificity) in order to retrieve most of the relevant studies [11]. Five electronic data sources were used:

(1) Medline; (2) Psychinfo; (3) EMBASE; (4) CINAHL; (5) Web of Science

Each database required a slightly different search strategy (see Appendix) to include articles that met the following criteria:

  • (a)

    Include a measure of

Results

The searches identified 550 studies, 203 from Web of Science, 199 from Medline, 72 from CINAHL, 52 from EMBASE, 25 from PsychInfo and a small number from cited references. Of these, 30 studies fulfilled the review criteria. These included three randomised-controlled studies, two non-randomised experimental studies, four longitudinal designs (no control group), 16 cross-sectional studies, one descriptive study and four qualitative designs (a full description of the studies available from the

Discussion and conclusion

Since there is consistent evidence that the quality of health care communication is associated with important patent outcomes in chronic illness, this review aimed to determine whether contradictory research findings about the association between patient-centred consultations and patient outcomes could be understood by investigating differences in definitions of patient-centredness. A review of 30 studies of health care communication in chronic illness found that the proposed distinction

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