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Abstract
Although `patient-centred' consulting skills are increasingly seen as crucial for the delivery of effective primary care, there is signicant
lack of clarity over the precise denition 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 identied, all of which reported some relationships between doctor behaviour dened 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 denitively.
# 2002 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Primary care; Patient-centredness; Outcomes; Doctorpatient 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 doctorpatient
relationship all highlight the need for good communication
[15]. However, despite general agreement on the importance of the broad construct of `patient-centredness', there is
less agreement about the exact denition of the term,
optimal methods of measurement, or the magnitude of
benets 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
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0738-3991/02/$ see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.
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confounders). It is known, for example, that patient satisfaction is positively related to patient age [1417], 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 condence 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 [1825]. 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 specic verbal behaviours
dened 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 (specically, `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
coefcients 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
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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]
No
Yes
No
No
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, doctorpatient
agreement, feeling understood,
level of discomfort, level of
concern, symptom resolution
Cape [21]
Yes
No
Audiotapes
Winefield
et al. [22]
No
Yes
Rating scale
No
No
No
Yes
Transcripts of
audiotapes
Transcripts of
audiotapes
Videotapes
Cecil and
Killeen [23]
Cohen's kappa:
0.840.90
Cohen's kappa 0.84
Satisfaction
Satisfaction
Satisfaction, self-report
compliance
Kinnersley
et al. [24]
No
No
Audiotapes
Stewart
et al. [25]
No
No
Audiotapes
Correlation of 0.83
14-Item patient-report
measure
No
No
Post-consultation
patient interviews
Not reported
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, doctorpatient
agreement, symptom resolution,
level of concern, change in
functional health status
Satisfaction, enablement
Study
Table 2
Data on measurement of patient-centredness and the relationship to dimensions of patient-centredness
Study
Dimensions [8]
Stewart [18]
Cape [21]
None
None
None
All `active' patient talk (expressed as a
ratio of doctor: patient talk)
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Table 3
Data on internal validity
Study
Power
Considered
unit of
analysis
problem?
Confounders
controlled for:
Results
Stewart [18]
No
No
NA
No
Yes
NA
Henbest and
Stewart [20]
No
Yes
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 0.38), task satisfaction (r 0.58),
ratio recall (r 0.47) and absolute recall (r
0.40). Doctors' `counselling' associated with global
satisfaction (r 0.38), task satisfaction (r 0.49),
ratio recall (r 0.38), absolute recall (r 0.46) and
impressions of boredom ( 0.46). No associations with
`humanness satisfaction'. Multivariate: NA
Univariate: patient-centredness score associated with
(patient-reported) doctorpatient discussion of reason
for coming (Spearman's r 0.42); doctor's understanding of importance of reason (r 0.30); knowing
what patient's reason was (r 0.33); patient feeling
understood (MannWhitney U 431.0, P < 0.01).
Significant association between patient-centred response to main symptom and post-consultation decrease
in patient concern (w2 7.30, P 0.03). No
associations with (i) doctorpatient agreement about
problem, (ii) symptom resolution, and (iii) patient
satisfaction. Multivariate (regression coefficients not
reported): associations with doctorpatient 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) doctorpatient 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 0.19). Multivariate: NA
Univariate: negative association between doctors'
`controlling' statements and self-report compliance
(Pearson's r 0.26). In paired analyses, significant
negative association with self-report compliance where
patients initiated `submissive' statements followed by
doctors' `controlling' statements (r 0.39). Negative association with patient satisfaction where doctors'
initiate `controlling' statements followed by patients'
`accepting' statements (r 0.25). No association
between patients' `assertiveness' and subsequent satisfaction. Multivariate: NA
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Table 3 (Continued )
Study
Power
Considered
unit of
analysis
problem?
Confounders
controlled for:
Results
Kinnersley
et al. [24]
Yes
Yes
Yes
Yes
Yes
Yes
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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
New or continuing
illness taking
medication
Simulations
Cape [21] UK
By invitation
9 (33% of
those invited)
77% of patients
completed data
collection
Consultations selected
from larger sample
Winefield
et al. [22]
Australia
Cecil and Killeen
[23] USA
Kinnersley
et al. [24] UK
Random sampling
19 (41% of
those sampled)
83% of consecutive
eligible patients
By invitation
15 (83% of
those invited)
143 (46% of
those sampled)
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
86
73
88
Not stated
190
50
Adult patients
consulting with
new illness
143
72% of eligible
patients
Adult patients
315
85% of eligible
patients (estimated)
Adult patients
173
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[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
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