Patient-centred consultations and outcomes in primary care: a

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Patient-centred consultations and outcomes in primary care: a
Patient Education and Counseling 48 (2002) 51±61
Patient-centred consultations and outcomes in primary care:
a review of the literature
Nicola Mead*, Peter Bower
National Primary Care Research and Development Centre (NPCRDC), University of Manchester, 5th Floor,
Williamson Building, Oxford Road, Manchester M13 9PL, UK
Received 25 July 2001; received in revised form 21 February 2002; accepted 28 April 2002
Abstract
Although `patient-centred' consulting skills are increasingly seen as crucial for the delivery of effective primary care, there is signi®cant
lack of clarity over the precise de®nition of the term, optimal methods of measurement, and the relationship between patient-centred care and
patient outcomes. The present study sought to review all empirical studies to date that have investigated the relationship between measures of
patient-centred consulting and outcomes in primary care, and to examine the methodological rigour of the studies. A number of observational
studies were identi®ed, all of which reported some relationships between doctor behaviour de®ned as `patient-centred' and a variety of patient
health outcomes. However, the pattern of associations was not clear or consistent, and some of the studies had shortcomings in terms of their
internal and external validity. Although the current evidence base may be suggestive of a relationship between patient-centred consulting
behaviour and patient outcomes, the case has not been made de®nitively.
# 2002 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Primary care; Patient-centredness; Outcomes; Doctor±patient relationship
1. Introduction
A `patient-centred' consulting style is increasingly advocated, particularly in primary care where complex undifferentiated problems, a high prevalence of psychosocial
disorder and the long-term nature of the doctor±patient
relationship all highlight the need for good communication
[1±5]. However, despite general agreement on the importance of the broad construct of `patient-centredness', there is
less agreement about the exact de®nition of the term,
optimal methods of measurement, or the magnitude of
bene®ts associated with it in terms of patient outcomes like
satisfaction, physical and emotional functioning.
1.1. Defining patient-centredness
`Patient-centredness' has been described in various ways in
the literature. Some highlight single issues, such as `understanding the patient as a unique human being' [6], or `[entering] the patient's world, to see the illness through the patient's
eyes' [2]. In contrast, Stewart et al. [7] describe multiple
*
Corresponding author. Tel: ‡44-161-255-7613;
fax: ‡44-161-255-7600.
E-mail address: [email protected] (N. Mead).
components of relevance: (i) exploring the disease and the
illness experience; (ii) understanding the whole person; (iii)
®nding common ground regarding management; (iv) incorporating prevention and health promotion; (v) enhancing the
doctor±patient relationship; and (vi) `being realistic' about
personal limitations and resources. Although there is some
common ground, variation in de®nitions highlight the need
for a clear conceptual framework. The present authors have
attempted to provide a preliminary framework, describing
®ve distinct dimensions of `patient-centred' care [8]:
(1) The biopsychosocial perspectiveÐa perspective on
illness that includes consideration of social and
psychological (as well as biomedical) factors.
(2) The `patient-as-person'Ðunderstanding the personal
meaning of the illness for each individual patient.
(3) Sharing power and responsibilityÐsensitivity to patients' preferences for information and shared decisionmaking and responding appropriately to these.
(4) The therapeutic allianceÐdeveloping common therapeutic goals and enhancing the personal bond between
doctor and patient.
(5) The `doctor-as-person'Ðawareness of the influence of
the personal qualities and subjectivity of the doctor on
the practise of medicine.
0738-3991/02/$ ± see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 0 9 9 - X
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N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
1.2. Measuring patient-centredness and its outcomes
Investigators have used a variety of methods for measuring patient-centredness including doctor and patient questionnaires and process measures of audio- or videotaped
consultations. In respect of the latter, patient-centred consulting has been variously operationalised using checklists
(to indicate the presence of certain skills), rating scales (to
measure the quality or quantity of particular behaviours) or
verbal coding schemes (to calculate frequencies or proportions of speci®c `utterances') [8]. The exact content of
different measures varies, re¯ecting the lack of clarity
surrounding the concept. Thus, empirical relationships
between different measures of patient-centredness are not
always high [9].
What is the relationship between patient-centred consulting and patient outcomes? At present, it is unclear what the
optimum outcome measure should be for such studies.
Although usually seen as the `gold standard' indicator of
effectiveness, health outcomes may not be sensitive to the
more interpersonal (as opposed to clinical) aspects of medical consultations. Process-referent measures, such as
patient satisfaction, may be more sensitive indicators of
the impact of doctors' communication style.
In a recent editorial, Stewart claims `evidence of tangible
bene®t' from patient-centred communication in terms of
improved satisfaction, adherence and health outcomes [10].
In support, she draws on an earlier comprehensive review of
`effective physician-patient communication and health outcomes' in which 16 out of 21 included studies reported
improvement in various patient-level outcomes such as
distress, functioning, physiologic measures (e.g. blood pressure) and health service utilisation [11]. However, the
reviewed studies covered a wide variety of clinical settings
and patient populations and, importantly, none measured
aspects of doctor±patient communication explicitly de®ned
as `patient-centred' by the respective investigators, a limitation highlighted by Graugaard and Finset [12]:
Evidence of the effectiveness of the patient-centred
model . . . has mostly been derived from studies that
have not speci®cally been designed to evaluate this
model but that, nevertheless, have been interpreted as
supporting one or a number of its elements.
If `patient-centredness' is a speci®c model of care that can
be taught and assessed, and not merely a diffuse concept that
subsumes the myriad ways in which doctors communicate
effectively with patients, bene®ts need to be demonstrated
using studies that explicitly relate patient-centred consulting
behaviour to outcome, preferably studies conducted within
similar clinical contexts.
1.3. Aims of the review
The present review sought to examine the following
issues:
(a) How has patient-centred consulting been de®ned and
measured in studies that explore relationships with
patient outcomes?
(b) What outcome measures have been used to examine the
effects of patient-centred consulting?
(c) Are patient-centred consultations associated with improved outcomes in primary care?
2. Method
2.1. The search strategy
Relevant empirical literature was identi®ed from searches
of computerised databases (Medline and PsychInfo) using
both UK and US spellings of the term `patient-centred(ness)'.
Searches were restricted to English language (non-nursing)
journals published between 1969 and 2000. Studies were
included in the review if they (1) utilised a quantitative
measure of a construct termed `patient-centred(ness)' (however, de®ned by the investigators), (2) included at least one
measure of consultation outcome at the level of the patient,
and (3) were conducted in a primary care setting, involving
quali®ed or trainee doctors (as opposed to other health
professionals). Although patient-centredness is also an
important concept in relation to other disciplines, there
may be important differences in meaning: doctors and nurses
differ in their conceptualisation of related terms such as
`holism' [13]. Also, the different clinical conditions under
which different professionals work (e.g. length of consultations, types of problems seen) means that the results found
for one professional group may not generalise to another.
The reference lists of studies examined for the review
were also searched for other relevant literature. A list of
excluded studies is available from the authors.
2.2. Data extraction
Data were extracted from selected studies on three key
issues of relevance.
2.2.1. Measurement issues
The various measures of patient-centred consulting used
by studies were examined in terms of their type and scope,
relationship to the proposed ®ve-dimension model of
patient-centred care [8] and issues of reliability and validity.
Data on outcome measures used in each study were also
extracted.
2.2.2. Internal validity
This refers to the con®dence with which one can assume
that a `cause±effect' relationship exists between two variables, namely (in this case) between patient-centred consulting behaviour and a particular outcome. Key issues
examined were study design, statistical power, and whether
studies controlled for sources of potential bias (such as
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
confounders). It is known, for example, that patient satisfaction is positively related to patient age [14±17], and this
relationship may account for an observed association
between patient-centredness and satisfaction unless the
confounding variable (patient age) is controlled for.
2.2.3. External validity
This refers to the con®dence with which the ®ndings of a
particular study can be generalised to other professionals,
patients and settings. Key issues examined were the methods
used to recruit doctors and patients, and the characteristics of
those who participated in the research.
Data were extracted by a single author (NM) and placed
into tables for ease of comparison.
3. Results
Eight published studies met the inclusion criteria for the
review [18±25]. One further study recently undertaken by
the present authors [26] was also included. Tables 1 and 2
present data on process and outcome measures used in the
studies. Data on internal and external validity can be found
in Tables 3 and 4, respectively.
3.1. Measurement issues
All the studies used verbal coding schemes as the basis for
measuring patient-centredness. In the majority of studies,
frequencies or proportions of speci®c verbal behaviours
de®ned by the investigators as `patient-centred' are calculated. However, one study [22] also used a rating scale to
score the doctor's best performance across ®ve `global'
interviewing skills, while three others use a variation of
the same measure (developed by Stewart and co-workers)
whereby doctors' responses to patients' verbal `offers' are
categorised then scored for the degree to which they facilitate further expression of the patient's illness experience
[20,24,25].
Only one study [21] used a measure that examined the
doctor's non-verbal behaviour (speci®cally, `use of
silence'). Four studies used measures that included aspects
of patients' (as well as doctors') verbal behaviour [18,22,
23,26].
All the included studies measured patient-centredness
using data from consultation audio- or videotapes, supplemented by patient interview in one study [25]. All but two
report inter-rater reliability of the measure, although the
statistical methods used to assess reliability varied widely,
including correlations, kappa scores, intra-class correlation
coef®cients and percentage agreement.
In terms of outcome measures, all but one study included
a measure of patients' satisfaction with their consultation.
However, there was wide variation both in the satisfaction
measures used and their mode of administration. Patients
completed the 29-item Medical Interview Satisfaction Scale
53
(MISS) [27] immediately following their consultation in two
of the studies [20,24]. Cape [21] also used the MISS,
supplemented by items from other measures of patients'
experience of therapeutic interactions, although these were
administered in semi-structured interviews with patients up
to 5 days after their visit. Two other studies administered
self-completion satisfaction measures immediately postconsultation [22,26]; the former used a 6-item rating scale
developed by the investigators while the latter used the 18item Consultation Satisfaction Questionnaire (CSQ) [28]. In
the study by Stewart [18], satisfaction was assessed using
17 questions (derived from a previously validated scale)
asked during face-to-face patient interviews 10 days after
the visit. Cecil and Killeen [23] used two ®ve-point scales
administered as part of a telephone survey 2±3 weeks after
patients' consultations. In the study by Roter et al. [19], three
students (acting as role-playing `patients') listened to audiotapes of consultations then rated their satisfaction across
eleven ®ve-point scales developed from the literature.
Other outcomes examined by the studies include more
speci®c measures of the patient's view of the consultation
(e.g. perceived doctor±patient agreement, feeling understood, feeling `enabled' [29], impressions of doctor affect)
[19,20,24,26], changes in health status [20,24,25], treatment
compliance [18,23], information recall [19] and utilisation
of health services [25].
Table 2 lists the speci®c doctor and patient behaviours
included in each measure of `patient-centredness' and notes
which of the ®ve dimensions of patient-centred care
(described earlier) each study appears to address, in the
opinion of the reviewers. All the measures examine some
aspect of the dimension `sharing power and responsibility'.
The majority also appear to address the `therapeutic alliance', although the focus seems to be on doctor rather than
patient behaviours. Five studies used measures that, in the
opinion of the reviewers, attempt to tap into the dimension of
`patient-as-person' [20±22,24,25]. There were fewer measures of the `biopsychosocial perspective' and none of the
`doctor-as-person' dimension of patient-centred care.
3.2. Internal validity
All the studies used an observational design rather than
experimental methods, and thus cannot provide rigorous
evidence that patient-centredness was causally related to
outcomes, as relationships found may be explained by
confounding factors. However, only four studies used multivariate statistical techniques to control for potential confounders [20,24±26]. Three studies report a power
calculation [24±26], and thus the rest were vulnerable to
Type II errors. Multiple hypothesis testing was common,
increasing the chance of Type I errors. An additional statistical issue of note is that when multiple consultations are
provided by individual doctors, there is a problem of `clustering', i.e. more similar outcomes among patients under the
care of a particular doctor [24]. This can cause incorrect
54
Table 1
Data on methodological issues in measurement
Instrument used or adapted to
measure patient-centred consulting
Type of measure
(checklist, rating scale, etc.)
Includes
non-verbal
behaviours?
Includes
patient
behaviours?
Method of
application
Inter-rater
reliability
Post-consultation patient
outcomes measured
Stewart [18]
Bales' Interaction Process
Analysis (IPA) [32]
Roter's Interaction
Analysis System (RIAS) [33]
Henbest and Stewart's method [34]
Verbal coding scheme
No
Yes
Verbal coding scheme
No
No
Verbal coding combined
with rating scales
No
No
Audiotapes and
transcripts
Transcripts of
audiotapes
Transcripts of
audiotapes
90.3% of statements
assigned same codes
Median correlation
of 0.81
Similar patient
`offers' noted
in 85% of cases;
correlation between
response scores
of 0.91
No formal
assessment
Satisfaction, self-report
compliance, pill count compliance
Satisfaction, impressions of doctor
affect, information recall
Satisfaction, doctor±patient
agreement, feeling understood,
level of discomfort, level of
concern, symptom resolution
Roter et al. [19]
Henbest and
Stewart [20]
Cape [21]
Byrne and Long's method [35]
Verbal coding scheme
Yes
No
Audiotapes
Winefield
et al. [22]
Stiles' Verbal Response
Modes (VRM) [36]
Farmer's patient-centredness
scale (unpublished) [22]
Relational Communication Control
Coding Scheme (RCCCS) [37]
Verbal coding scheme
No
Yes
Rating scale
No
No
Verbal coding scheme
No
Yes
Transcripts of
audiotapes
Transcripts of
audiotapes
Videotapes
Cecil and
Killeen [23]
Cohen's kappa:
0.84±0.90
Cohen's kappa 0.84
Satisfaction
Satisfaction
Cohen's kappa for
allocating codes
to `verbal
messages': 0.85
One rater used so
assessed intra-rater
reliability only
Satisfaction, self-report
compliance
Level of discomfort, level of
concern, self-report health status,
number of visits to the doctor,
tests and referrals
Level of discomfort, level of
concern, self-report health status,
number of visits to the doctor,
tests and referrals
Kinnersley
et al. [24]
Brown et al.'s method [38]
Verbal coding combined
with rating scales
and checklists
No
No
Audiotapes
Stewart
et al. [25]
Brown et al.'s method [38]
Verbal coding combined
with rating scales
and checklists
No
No
Audiotapes
Correlation of 0.83
Patient perceptions of patientcentredness questionnaire [25]
14-Item patient-report
measure
No
No
Post-consultation
patient interviews
Not reported
Roter Interaction Analysis
System (RIAS) [33]
Verbal coding scheme
No
Yes
Videotapes
Mean intra-class
coefficient for coded
patient behaviours of
0.61 and doctor
behaviours of 0.71
Mead
et al. [26]
Satisfaction, patient experience
of the consultation
Satisfaction, doctor±patient
agreement, symptom resolution,
level of concern, change in
functional health status
Satisfaction, enablement
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
Study
Table 2
Data on measurement of patient-centredness and the relationship to dimensions of patient-centredness
Study
Doctor behaviours measured
Patient behaviours measured
Dimensions [8]
Stewart [18]
`Supportive' behaviours: shows solidarity, expresses tension release,
agrees/understands; `encouraging patient expression':
asks for opinion, suggestion, help
Sharing power and responsibility;
therapeutic alliance
Roter et al. [19]
Giving information/orientation/opinion relating to medical procedures,
condition, therapy or prevention; counselling about prevention,
lifestyle or therapy
Doctor's responses to patient `offers' (of symptoms, thoughts,
feelings, expectations or prompts); responses categorised as
`ignores', `closed', `open' or `specific facilitation'
`Expression of feelings': gives opinion; disagrees;
shows tension; shows antagonism, `providing
information': gives suggestion; gives
orientation/information
None
Cape [21]
Winefield et al. [22]
Wide range of behaviours primarily focused on eliciting and using
patient knowledge and experience, e.g. open questions, seeking &
using patient ideas, offering and accepting feeling, reassuring,
encouraging, using silence, etc.
`Doctor receptiveness': open questions; reflections, acknowledgements
Cecil and Killeen [23]
Soliciting patient's views; responding to patient's views; relating
information to patient's views; involving patients in management;
checking understanding
Verbal behaviours coded as `controlling', `accepting' or `neutral'
Kinnersley et al. [24]
Stewart et al. [25]
Mead et al. [26]
`Exploring the disease & illness experience': doctor's responses
(preliminary exploration, further exploration, cut-off) to patient
`offers'; `understanding whole person': eliciting & exploring life cycle,
personality and social issues; `finding common ground': clear expression
of problem and management goals; giving patient opportunity to ask
questions; engaging in mutual discussion; clarifying agreements;
flexible response to disagreements
As for Kinnersley et al. [24]
Perceived extent of doctor's discussion & explanation of problem
and treatment; giving opinion; giving opportunity for patient to ask
questions; asking about treatment goals; discussion of respective roles, etc.
Psychosocial/lifestyle questions; biomedical information-giving;
soliciting patient opinions; checking understanding; social talk;
reassurances; encouragement; ratings of warmth/friendliness
and interest/concern
None (number of patient `offers' used only as
denominator to calculate doctor's
patient-centredness score)
Patient-as-person; sharing power and
responsibility; therapeutic alliance
(biopsychosocial perspective)
None
Patient-as-person; sharing power and
responsibility; therapeutic alliance
`Patient involvement': questions; positive and
negative attitudes to treatment; accounts of
private (unobservable) symptoms; accounts of
actions; opinions
None
Patient-as-person; sharing power and
responsibility; therapeutic alliance
(biopsychosocial perspective)
Verbal behaviours coded as `controlling',
`accepting' or `neutral'
None
None
None
All `active' patient talk (expressed as a
ratio of doctor: patient talk)
Patient-as-person; sharing power and
responsibility; therapeutic alliance
Sharing power and responsibility
Patient-as-person; sharing power and
responsibility; therapeutic alliance
(biopsychosocial perspective)
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
Henbest and Stewart [20]
Biopsychosocial perspective; sharing
power and responsibility
Patient-as-person; sharing power and
responsibility; therapeutic alliance
(biopsychosocial perspective)
Sharing power and responsibility;
therapeutic alliance
Biopsychosocial perspective; sharing
power and responsibility; therapeutic
alliance
55
56
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
Table 3
Data on internal validity
Study
Power
Considered
unit of
analysis
problem?
Confounders
controlled for:
Results
Stewart [18]
No
No
NA
Roter et al. [19]
No
Yes
NA
Henbest and
Stewart [20]
No
Yes
Patient age, sex, occupation, education,
SEC and marital status; doctor; type
and severity of problem; consultation
length; regular doctor; who originated
appointment; past frequency of contact;
duration of relationship with doctor
Cape [21]
No
No
NA
Winefield
et al. [22]
No
No
NA
Cecil and
Killeen [23]
No
No
NA
Univariate: high proportion of patient-centred behaviours by doctor (i.e. >sample median) associated with
higher patient-reported compliance (57.8% versus
34.5%, P 0.05), but no associations with pill count
or patient satisfaction. High proportion of patientcentred behaviours expressed by patient not associated
with satisfaction, reported compliance or pill count.
Multivariate: NA
Univariate (proportionate measures): doctors' `information-giving' associated with: global satisfaction
(Pearson's r ˆ 0.38), task satisfaction (r ˆ 0.58),
ratio recall (r ˆ 0.47) and absolute recall (r ˆ
0.40). Doctors' `counselling' associated with global
satisfaction (r ˆ 0.38), task satisfaction (r ˆ 0.49),
ratio recall (r ˆ 0.38), absolute recall (r ˆ 0.46) and
impressions of boredom ( 0.46). No associations with
`humanness satisfaction'. Multivariate: NA
Univariate: patient-centredness score associated with
(patient-reported) doctor±patient discussion of reason
for coming (Spearman's r ˆ 0.42); doctor's understanding of importance of reason (r ˆ 0.30); knowing
what patient's reason was (r ˆ 0.33); patient feeling
understood (Mann±Whitney U ˆ 431.0, P < 0.01).
Significant association between patient-centred response to main symptom and post-consultation decrease
in patient concern (w2 ˆ 7.30, P ˆ 0.03). No
associations with (i) doctor±patient agreement about
problem, (ii) symptom resolution, and (iii) patient
satisfaction. Multivariate (regression coefficients not
reported): associations with doctor±patient discussion
of reason for coming and understanding importance of
reason. Association between patient-centredness of
response to main symptom and decreased patient
concern. No associations with (i) knowing patient's
reason for consulting, (ii) doctor±patient agreement
about problem, (iii) patient feeling understood, (iv)
symptom resolution, and (v) patient satisfaction.
Univariate: no association with (i) interview rating of
patients' consultation experience, or (ii) patients' overall satisfaction. Multivariate: NA
Univariate: (i) verbal coding measure: no associations
between `doctor receptiveness' or `patient involvement'
(either in diagnostic or prescriptive stage of consultation, or overall) and patient satisfaction; (ii) rating scale
measure: significant association between overall rating
of doctor's patient-centredness and patient satisfaction
(Pearson's r ˆ 0.19). Multivariate: NA
Univariate: negative association between doctors'
`controlling' statements and self-report compliance
(Pearson's r ˆ 0.26). In paired analyses, significant
negative association with self-report compliance where
patients initiated `submissive' statements followed by
doctors' `controlling' statements (r ˆ 0.39). Negative association with patient satisfaction where doctors'
initiate `controlling' statements followed by patients'
`accepting' statements (r ˆ 0.25). No association
between patients' `assertiveness' and subsequent satisfaction. Multivariate: NA
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
57
Table 3 (Continued )
Study
Power
Considered
unit of
analysis
problem?
Confounders
controlled for:
Results
Kinnersley
et al. [24]
Yes
Yes
Patient marital status & morbidity, age,
sex, education, SES, long-standing
illness, acquaintance with doctor,
consultations in 12m; doctor sex, doctor patient sex, year of qualification; levels
of patient concern & discomfort;
prescription; referral; doctor-rated
prognosis
Stewart et al. [25]
Yes
Yes
Patient marital status, type of main
problem; baseline levels of
discomfort and concern
Mead et al. [26]
Yes
Yes
Patient age, sex, psychological
morbidity; physical activity level,
change in health in past 2 weeks;
blood pressure checked, new
prescription issued, consultation
length, new physical problem; GP
acquaintance with patient
Univariate: association between patient-centred score
and patient satisfaction (Pearson's r ˆ 0.26). No
associations with doctor±patient agreement, resolution
of symptoms, resolution of concerns or functional health
status. Multivariate: patient-centred score and patient
satisfaction (adjusted): B ˆ 1.57 (P ˆ 0.003). No
significant relationships (adjusted for confounders) with
doctor±patient agreement, resolution of symptoms,
resolution of concerns or functional health status.
Univariate: none reported. Multivariate: (i) objective
measure: no associations between patient-centredness
score and any patient health or medical care outcomes;
(ii) patient-report measure: total score associated with
reduced levels of discomfort and concern, better mental
health status, fewer diagnostic tests and referrals.
Univariate: associations between two measures of
patient-centred behaviour and patients' satisfaction, i.e.
`verbal caring' (social talk, reassurances and encouragement), r ˆ 0.19; and `non-verbal caring' (ˆ rated
GP warmth and concern), r ˆ 0.22. No associations
with three other measures of patient-centred behaviour
and none with patients' post-consultation enablement.
Multivariate: No associations between any of the five
patient-centred behaviours measured and (i) patient
enablement or (ii) patient satisfaction (adjusting for
confounding variables).
estimation of signi®cance levels. Five studies addressed this
unit of analysis problem: one used scores aggregated at a
higher level unit [19], three dealt with the problem statistically [20,25,26] and one dealt with it through design,
whereby only one consultation per participating doctor
was randomly selected for analysis [24].
3.3. External validity
Generally, studies provided relatively little information
about the doctors who took part. Only three attempted to
recruit doctors using random sampling methods [22,24,25],
each reporting similar uptake rates (between 41 and 47%).
This may be considered a reasonable participation rate
considering that the studies all involved audiotaping (which
is quite intrusive and potentially threatening).
The remaining studies are of poorer quality in that all
employed convenience sampling. For example, Stewart [18],
Roter et al. [19] and Cape [21] recruited doctors known to
have particular expertise or interest (e.g. in `the doctor±
patient relationship' [18]). Cecil and Killeen [23] recruited
doctors from one clinic only, while general practitioners
were recruited via university-based research networks to the
study by Mead et al. [26].
There is some evidence that doctors who took part in these
studies were not representative of the wider physician
population. Even in the studies that used random sampling,
Kinnersley et al. [24] and Stewart et al. [25] both report
that participants were signi®cantly more likely than nonparticipants to be members of their respective country's
professional college. Eighty-six percent of GP volunteers
to the study by Mead et al. [26] were members of the UK
Royal College of General Practitioners, whereas national
membership is more in the region of 50%. Kinnersley et al.
also found that participating GPs had been quali®ed fewer
years than non-participants [24]: it is possible that younger,
more recently quali®ed doctors may have received speci®c
communication skills training and, therefore, feel more
con®dent in this area. This may restrict the range in process
and outcome measurements recorded in a study (e.g. if no
doctors obtain particularly low patient-centredness scores),
which may in turn reduce the magnitude of correlations
between variables. One study reports an age range (23±44
years) suggestive of a relatively young and recently quali®ed
group of doctors [22], although there appears more variation
in the sample recruited by Mead et al. [26]. Six studies report
the sex of participating doctors, who were predominantly
male (ranging from 72 to 100%). In this respect, the studies
all seem fairly representative.
In terms of patient recruitment, the seven studies in which
consecutive (eligible) patients were approached over a set
study period report quite high participation rates (72±94%).
Cecil and Killeen [23] used convenience sampling to obtain
a `representative sample' of patients, which is a less robust
58
Table 4
Data on external validity
Doctor recruitment
No. of
participating
doctors
Participating doctor
characteristics
Patient recruitment
and response rate
Inclusion criteria
No. of
consultations
studied
Patient characteristics
Stewart [18] ±
Canada
By invitation
22 (92% of
those invited)
None stated
74% of eligible
patients
140
Roter et al.
[19] ± USA
Henbest and Stewart
[20] ± Canada
Not stated
43
Non-patient volunteers
Not stated
6
Primary care physicians
(100% male)
Experienced family doctors
New or continuing
illness taking
medication
Simulations
Cape [21] ± UK
By invitation
9 (33% of
those invited)
78% male, mean experience
19.6 years
77% of patients
completed data
collection
Consultations selected
from larger sample
Age: 1±22 years (38%), 23±44
years (24%), 45±64 years (24%),
>65 years (10%); sex: 58% female
Simulated patients so not
applicable
Age: unclear; sex: 66% female
Winefield
et al. [22] ±
Australia
Cecil and Killeen
[23] ± USA
Kinnersley
et al. [24] ± UK
Random sampling
19 (41% of
those sampled)
Aged 23±44 years, average
10 years since graduation
83% of consecutive
eligible patients
By invitation
15 (83% of
those invited)
143 (46% of
those sampled)
73% male, mix of experience
Convenience
sampling
88% of patients
Random sampling
Stewart et al.
[25] ± Canada
Random sampling
39 (47% of
those sampled)
Mead et al.
[26] ± UK
By invitation
14
72% male, 52% with
10±19 years experience,
more likely to hold MRCGP
than non-participants
72% male, more likely to
be certificants of College
of Family Physicians of
Canada than non-participants
86% male, aged
33±56 years (mean: 44.9 years)
with between 3±23 years
experience (mean: 14.4 years);
86% held MRCGP
86
Adults with new
symptom presentation
73
Aged 18±75 years,
presenting emotional
problem
Adult patients
88
Not stated
190
50
Age: mean ˆ 43.9 years
(range: 19±75); sex: 78% female
Age: mean ˆ 46.2 years; sex:
67% female
Age: mean ˆ 37 years
(range: 18±81); sex: 70% female
Age: mean ˆ 44.8 years; sex:
66% female
Adult patients
consulting with
new illness
143
72% of eligible
patients
Adult patients
315
Age: 18±44 years (61%); 45±64
years (24%); >65 years (14%);
sex: 54% female
85% of eligible
patients (estimated)
Adult patients
173
Age: mean ˆ 47.9 years
(range: 17±90); sex: 54% female
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
Study & country
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
method. The study by Roter et al. [19] used simulated
patients and raters; thus, the external validity of this study
is very limited.
The typical patient participant in these studies was
female, mid-40s, and married. Little information was provided about socio-economic status or levels of educational
attainment, and cross-national comparisons are often dif®cult in this respect. Only two studies gave information
comparing participating patients with non-participants.
One found that refusers were older but had a similar sex
distribution to participants [18], although the second found
that participants were representative of all eligible patients
in terms of age but not sex (with fewer females agreeing to
take part) [25].
3.4. Summary of findings of the included studies
Five studies report univariate results only [18,19,21±23]
(see Table 3). Of these, only one found no relationship
between patient-centredness and outcome [21]. However,
most of these studies tested multiple hypotheses and all
report non-signi®cant correlations between some measures
of patient-centred consulting and outcomes. Patient satisfaction was the most commonly studied outcome: no association is reported in two studies [18,21], two others found
some evidence of a relationship [19,23] and one reported
both a signi®cant and a non-signi®cant association, depending on the measure of patient-centredness used [22].
Of the four studies that used multivariate analyses to
control for confounders, one reported an association with
patient satisfaction but not with other health outcomes [24].
Two others failed to ®nd an association with satisfaction
[20,26], although the former did report associations with
patients' perceptions of the consultation process and with
reduced levels of concern. No association was found
between patient-centred consulting and patient enablement
in the study by Mead et al. [26]. The fourth study failed to
detect any association between an objective measure of
patient-centred communication and patient health outcomes,
but reported that patients' own perceptions of the patientcentredness of their consultation did predict health status
and health utilisation outcomes [25].
4. Discussion and conclusion
Primary care studies examining the relationship between
consultation patient-centredness (as de®ned and operationalised by the respective investigators) and patient outcomes
were identi®ed for this review. An alternative approach
would have been to de®ne `patient-centredness' a priori,
then search for all studies measuring aspects of doctor±
patient communication that met that de®nition. While
the latter approach may have had advantages theoretically,
it was not taken for two reasons. First, there is no universally agreed de®nition of `patient-centredness'; the present
59
approach, therefore, circumvents this problem by relying on
investigators themselves to identify their study as relating
to the construct. Secondly, the adopted approach restricted
analysis to a limited number of studies, allowing more
comprehensive consideration of the methodological detail
of each.
Generally, internal validity was not high. Stewart also
reported that observational studies included in her review
often failed to control for important confounders [11].
However, it should be noted that more recently published
studies are using more sophisticated and appropriate design
and analytical techniques [24±26].
The external validity of studies was also not high. However, the very nature of the methodology used by most
studies (i.e. relatively intrusive measures of the consultation
process) means that improving external validity might be
dif®cult. Certain doctors are unlikely to agree to take part in
such studies (e.g. those with poor self-assessed communication skills). Moreover, patients with particularly sensitive
physical or psychosocial problems (where patient-centred
consulting skills may be of utmost importance) may not be
willing to have their consultations studied [30].
It is possible, however, for studies to improve reporting of
differences between participants and non-participants. To
facilitate judgements about representativeness and crossstudy comparisons, future research should present details
of those doctors who participate (and those who refuse),
including age, sex and clinical experience. Similar basic
information about the patient population should also be
supplied.
The different methods used to operationalise patientcentredness in these studies re¯ect current ambiguity over
de®nition of the term. Is patient-centredness primarily part
of the doctor's clinical method or should patients' behaviour
in the consultation also be considered? Although few would
doubt the importance of non-verbal interpersonal skills for
delivering patient-centred care, these are rarely examined
(see Tables 1 and 2) and may be dif®cult to measure
objectively. Although the study by Mead et al. [26] included
a measure of non-verbal `caring' (based on observer ratings
of doctors' `warmth/friendliness' and `interest/concern'),
the inter-rater reliability of that measure was poor and it
was highly correlated with a measure of the doctors' verbal
`caring' (e.g. expressions of reassurance).
As to the question of whether patient-centred consultations
lead to better patient outcomes, results of the studies reviewed
here are ambiguous. Most of those that use univariate analyses
report some positive relationships, but ®ndings in relation to
the most frequently measured outcome (i.e. patient satisfaction) are equally split between signi®cant and non-signi®cant
results (see Table 3). Studies that employ more sophisticated
multivariate analyses are also split in terms of relationships
with satisfaction. Moreover, there are no obvious patterns in
relation to other outcomes that have been studied.
As suggested above, a key problem is the lack of a clear
theoretical framework linking speci®c dimensions of
60
N. Mead, P. Bower / Patient Education and Counseling 48 (2002) 51±61
patient-centred care with speci®c outcomes. For example,
consulting behaviours aimed at `sharing power and responsibility' may be more likely to predict adherence-type outcomes than the doctor's use of a `biopsychosocial
perspective', while attention to the `therapeutic alliance'
may be a better predictor of patient satisfaction than either of
those two dimensions [26]. One way of improving the
interpretability of future studies would be for authors to
explicitly link their measures of the consultation to one of
the two multi-dimensional models of patient-centred care
that have been proposed in [7,8]. Another improvement
would be for studies to use the same validated measures
of outcome (e.g. the MISS or CSQ to measure patient
satisfaction).
4.1. Conclusion
How does the present review relate to that undertaken by
Stewart [11]? The two reviews have important differences,
for example in terms of the context of included studies (i.e.
primary care versus a wider range of clinical settings), study
design (i.e. observational studies only versus a mix of
observational and experimental designs) and inclusion criteria for the review (i.e. studies that include a measure of the
consultation process versus a mix of process research and
intervention studies that did not incorporate process measurement). More broadly, the Stewart review was concerned
with communication skills in general rather than behaviour
explicitly de®ned as `patient-centred'. The positive conclusions of the Stewart review and the more guarded conclusions of the present paper may relate to any or all of these
differences. However, the ®ndings of the present review do
provide some support for the view that speci®c evidence of
the bene®ts of patient-centredness is somewhat lacking at
present [12,31].
4.2. Practice implications
In conclusion, the evidence that patient-centred consulting leads to better patient outcomes in primary care is
ambiguous to date, as the methodological quality of studies
is not uniformly high and the pattern of associations is
inconsistent. Improved research is required if interventions
in communication skills associated with the concept of
`patient-centredness' are to be appropriately targeted.
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