How Clinician-Patient Communication Can Improve Health Outcomes Richard L. Street, Jr. Texas A&M University June 8, 2010
Jun 01, 2015
How Clinician-Patient Communication Can Improve
Health Outcomes
Richard L. Street, Jr.Texas A&M University
June 8, 2010
The problem: How does one explain these findings?
Kaplan et al (1988)◦ Patient efforts to exert control—lower blood
pressure and lower A1c 8-12 weeks after the consultation
◦ More equal dr-pt floortime—fewer functional limitations 8-12 weeks after visit
Orth et al (1987)◦lower blood pressure at 2 weeks related
to:◦ Proportion of physician talk that was
explaining/describing/reporting—◦ Frequency of patient talk that expressed
concerns/described symptoms—lower blood pressure at 2 weeks
Stewart et al (2000)◦Patient perception of dr patient-
centeredness (e.g, exploring problem, finding common ground)—better emotional well-being 2 months after visit
Street et al (1993)◦Less nurse controlling behavior—better
A1c control at 2 monthsWard et al (2003)
◦More active patient participation among lupus pts—less organ damage at three years
But then what about these findings?
Amount of dr. information—more functional limitations and lower self-reported health (Kaplan et al, 1988)
Pt effort to participate in decision-making not related to subsequent A1c (Rost et al, 1991)
Dr. patient-centered communication (partnership-building, supportive) not related to lupus patients’ outcomes (Ward et al, 2003)
Negative affect related to better A1c (Kaplan et al., 1988) and poorer A1c (Street et al, 1993)
Or these?Observer coded PCC (exploring pt.
problem, finding common ground) (Stewart et al., 2000):◦ was not related to pt’s emotional well-being◦ only modestly correlated with pt. perception of
PCCActive pt. participation in deciding breast
cancer treatment (Street et al, 1995):◦ did not predict breast cancer patients’
emotional and functional well-being at 1 year following treatment
◦ did predict patient assuming responsibility for decision at 1 year which in turn predicted well-being
PCC trained doctors and diabetes outcomes (Kinmonth et al, 1998)◦ With trained drs, patients were happier and
fatter
Clinician-Patient
Communication
Patient Health
Outcomes
Theoretical pathways
Conceptual/Measurement challenges
7
8
Patient-Centered COMMUNICATION:Six overlapping functions
Epstein MR and Street RL. Patient-centered communication in cancer care:Promoting healing and reducing suffering. NCI, NIH publication #07-6225, Bethesda MD, 2007 http://www.outcomes.cancer.gov/areas/pcc/communication
Clinician-Patient Communication Processes
Proximal Outcomes*understanding*satisfaction*clinician-patient agreement*trust*feeling ‘known’*patient feels involved*rapport*motivation
Intermediate Outcomes*access to care*quality medical decision*commitment to treatment*trust in system*social support*self-care skills*emotional management
Health outcomes*survival*cure/remission*less suffering*emotional well-being*pain control*functional ability*vitality
Indirect (mediated) path
Direct path
Exploring pathways: A research agenda
Identify the health outcome of interest
Identify the mechanism for improved health
Model the pathway through which communication can lead to improved health
Select appropriate measures for communication variables, proximal outcomes, and intermediate outcomes
Develop intervention to target communication process to activate that mechanism
Pain Control in Cancer Outcome: Better pain control at 2
weeks Pathway:
◦ Effective use of pain medication Proximal outcomes
◦ Change in pain medication (new medication, change in dose)
Communication variables◦ Active patient participation about pain
(asking questions, expressing concern, being assertive)
Intervention: patient activation coaching intervention
◦ Emphasize importance of patient involvement, educate about pain management, provide opportunities for practice talking to the doctor and feedback on performance
ActivePatientParticipation
Change in pain meds
Coachingintervention
Pain controlat 2 weeks
Cancer Health Empowerment for Living without Cancer Pain (Ca-HELP) Study (R.L. Kravitz, PI)
Research settings◦ Patient of UC Davis Cancer Center, Kaiser
Permanente oncology clinics in Sacramento and Roseville, Sacramento VA Health Care System
Research participants◦ Age 18-80◦ Cancers: breast, prostate, lung, head/neck,
pancreatic, colorectal, esophageal◦ Worst pain of 4 or greater or worst pain of 3
with impairment of daily activities◦ Not in hospice◦ No more than one pain management
consultation
Research measures Frequency measures (Street, 2001)
◦ Patient involvement-pain specific (frequency of patients’ questions, assertive statements, and concerns specific about pain) overall and pain-specific
Ratings measures◦ Coders’ ratings of participatory decision-
making (Kaplan et al, 1995) Change in pain medication
◦ Patient self-report to question, “During the visit you just completed, did the physician recommended any change in your pain medication? “ (Yes--new medicine,; Yes--change in dose or amount of a medicine; No)
Characteristics of the sample(N = 148)
Intervention Control P
N 77 71
Mean age (yrs) 60 57 <.03
% women 78% 84% ns
% white 67% 75% ns
% college degree 37% 46% ns
Total PatientParticipation
(N = 148)
Pain-SpecificParticipation
(N = 148)
Predictor Estimate
(SE)
P Estimate
(SE)
P
Patient race = Caucasian
(ref = non-Caucasian)
0.88 (1.43) .54 -0.27 (0.61) .65
Patient’s age -0.20 (0.08) .01 -0.03 (0.03) .29
Patient’s education = HS or
less
(ref = some college plus)
-1.59 (1.48) .29 0.38 (0.64) .56
Patient gender = female
(ref = male)
0.71 (1.75) .69 0.66 (0.76) .39
Patient baseline pain 1.01 (0.36) .005 0.48 (0.15) .002
Physician participatory
decision-making
0.26 (0.09) .006 0.13 (0.040 .001
Accompanied = yes
(ref = no)
0.15 (1.60) .93 0.36 (0.69) .60
Education session =
(ref = control)
0.54 (1.32) .68 1.51 (0.57) 0.009
Predictors of Active Patient Participation (Street et al., 2010)
Model 1
(N = 134)
Model 2
(N = 134)
Predictor Estimate
(SE)
P Estimate
(SE)
P
Patient race = Caucasian
(ref = non-Caucasian)
-0.03 (0.09) .ns -0.01 (0.09) ns
Patient’s age -0.01 (0.00) .02 -0.01 (0.00) .02
Patient’s education = HS or less
(ref = some college plus)
-0.01 (0.10) .29 -0.05(0.09) ns
Patient gender = female
(ref = male)
-0.05 (0.11) ns -0.11 (0.11) ns
Patient baseline pain 0.03 (0.03) ns 0.01 (0.02) ns
Accompanied = yes
(ref = no)
-0.03 (0.11) ns 0.36 (0.69) .60
Education session =
(ref = control)
0.27 (0.9) 0.003 0.19 (0.08) 0.04
Active patient participation
(pain-specific)
0.06 (0.01) <.0001
Predictors of Pain Medication Adjustment
ActivePatientParticipation
Change in pain meds
Coachingintervention
Pain controlat 2 weeks
Baselinepain
_
Pain Control and Better Knee Function for Patients having Acupuncture for
Osteoarthritis Outcome: Better pain control and
function
Pathway ◦ Placebo effect through beliefs about
acupuncture
Proximal outcomes◦ Patient expectations that acupuncture will
improve pain and function
Communication Intervention◦ Acupuncturists communicating high vs.
neutral expectations for treatment success
For the first half of the trial half of the acupuncturists were randomly allocated to the high expectations communication style and the other half to the neutral style. In the second half the acupuncturists switched communication styles.
The Houston Arthritis and Acupuncture Treatment Study (HAATS) (PI, M. Suarez-Almazor)
Communicating High vs Neutral Expectations
High expectations◦ “I’ve had a lot of success with patients with
your kind of knee pain”◦ “I’m optimistic this is going to work for you.”◦ “You should start feeling better within 4 or 5
treatments”◦ “Sometimes it just takes a little longer to
work, but it usually does” Neutral expectations
◦ “It works for some patients and not for others.” “I am not sure if it’ll work. We just have to wait and see if it helps you”
◦ “It may be that it’s not working, maybe it will after a few more treatments”
Research measures Communication expectation measure
◦ Coders’ rating on 100mm scale at baseline visit
◦ Based on what you heard, rate this practitioner’s communication style when discussing treatment expectations for improvement.
◦ Neutral ___________________________________High
Patient expectations (assessed at 4 weeks)◦ For each condition (e.g., knee pain, stiffness), please choose
how you would expect it to be 2 MONTHS from now after you have completed the Acupuncture Treatment. (Much worse, Worse, The same. Better, Much Better)
Pain and Function measures◦ WOMAC scale response at + 6 weeks and + 3 months◦ Pain—How much pain do you have ‘walking on a flat surface,’
‘going and down stairs,’ etc◦ Function—What degree of difficulty do you have with
‘ascending stairs,’ ‘getting in/out of car,’
High Expectations Neutral ExpectationsTCA
N=75ShamN=151
TCAN=78
ShamN=151
p+
GENDER, females – n (%) 51 (68.0%) 97 (64.2%) 50 (64.1%) 98 (64.9%) > 0.20AGE 63.5 (10.4) 65.3 (9.0) 65.5 (7.8) 63.7 (9.1) > 0.20ETHNICITY – n (%) Whites
African American
Hispanic
Other
52 (69.3%)
16 (21.3%)
4 (5.3%)
3 (4.0%)
103 (68.2%)
23 (15.2%)
14 (9.3%)
11 (7.3%)
55 (70.5%)
13 (16.7%)
8 (10.3%)
2 (2.6%)
101 (66.9%)
31 (20.5%)
14 (9.3%)
5 (3.3%)
> 0.20
EDUCATIONAL LEVEL – n (%)Less than high school
High School diploma/some college
College degree
2 (2.7%)34 (45.3%)39 (52.0%)
5 (3.3%)79 (52.3%)67 (44.4%)
3 (3.8%)35 (44.9%)40 (51.3%)
3 (2.0%)72 (48.0%)75 (50%)
> 0.20
DURATION OF KNEE PAIN, years
10.0 (11.7) 8.4 (9.6) 8.4 (7.9) 8.8 (10.4) 0.14
J-MAP 4.4 (1.2) 4.3 (1.3) 4.5 (1.3) 4.6 (1.2) 0.12
WOMAC Pain 43.3 (18.2) 44.8 (18.7) 45.6 (18.6) 45.2 (17.8) > 0.20
WOMAC Function 41.5 (19.3) 45.1 (18.5) 44.2 (18.8) 44.1 (17.6) > 0.20
Baseline demographic and clinical characteristics
.77-.32
.37
.11
Pain
6wk
Patient Expectations Acupuncture Effectiveness
(4 weeks)
Expectations Communicated
(baseline)Pain
3 months
Patient Baseline
Expectations
Results of Path Analysis
All effects were significant, P < .05
good overall model fit: chi-square=5.2, p=.39, RMSEA=.01
Another pathway? Shared Mind
Epstein and Peters (2009)“Collaborative cognition depends on
the physician being mindful not only of the patient’s values, thoughts, and feelings but also his or her own. Research exploring shared deliberation and shared mind must bridge cognitive science, decision research, and communication skills training and evaluate communication processes as well as patients’ experience of care” (p. 197).
Shared mind is a process:◦A way of thinking◦A way of talking◦A way of collaborating
Shared mind is also an outcome◦Shared understanding of the
problem◦Understanding the others’
perspective◦Reaching agreement on a course of
action
Types of shared understanding
Similar beliefs◦What physician believes coincides with
what patient believesPerceived agreement (fantasy)
◦What physician believes coincides with what physician believes patient believes
Understanding of the other (perspective-taking)◦What physician believes the patient
believes coincides with what the patient believes
SharedMind
PT DR
The CONNECT study (PI, P. Haidet)
Determine how well physicians understand their patient’s health belief models
Identify predictors of greater understanding (more accurate perspective taking)◦Communication factors—more active
patient participation (asking questions, expressing concerns, stating opinion and preferences)
◦Relationship factors—number of previous visits, racial/gender concordance
◦Cultural factors—as assessed by physician-patient demographics
The CONNECT instrument: Six domains of health beliefs (*Haidet et al,
Patient Education and Counseling 2008)To what extent:is there a biological cause to the
patient’s health conditionis the patient at fault for his/her health
conditiondoes the patient have control over
his/her health conditiondoes the condition have meaning for
the patientcan the patient’s health condition benefit
from natural/alternative remediesdoes patient want a partnership with
the doctor
Study Design: cross-sectional using pre- and post-visit surveys, audiotapes of primary care encounters
Setting: 10 primary care clinics in Houston, TX
Subjects: 272 adult patients receiving care from 29 physicians
The CONNECT Instrument*
Six domains of explanatory models (cause, fault, control, meaning, alternative treatments, relationship)
Respondent/Focus Instrument Item
Patient Own: “I have control over my illness”
Doctor own: “The patient has control over their illness”
Doc Understanding: The patient thinks he/she has control over their illness”
*Haidet et al, Patient Education and Counseling 2008
Data AnalysisSummary scores for each
CONNECT domainCompared domain sum scores
between patient own and physician understanding
Used multivariate models to examine predictors of greater physician udnerstanding
Accounted for effect of patients nested within physicians
Results: Study PopulationPatients (n=272) Physicians
(n=29)Mean age, yrs 56 (15)
Female (%) 60
AA (%) 50
Caucasian (%) 39
Hispanic (%) 11
Mean age, yrs 43 (9)
Female (%) 58
AA (%) 26
Caucasian (%) 32
Hispanic (%) 3
Asian (%) 39
Domain
A
Physician
Model
B
Physician Belief
about Patient
Model
C
Patient
Model
Difference
A vs. B
(P-value)
Difference
B vs. C
(P-value)
Cause-Biological 71.4 74.4 67.4 .059 0.009
Patient at Fault 49.1 49.1 55.0 ns <0.001
Patient has Control 78.4 75.8 82.8 0.018 <0.001
Meaning to the Patient 71.0 72.1 79.6 ns <0.001
Value of Alternative
Treatments
50.7 50.8 56.7 ns <0.001
Patient wants to be
Partner in
Relationship
82.5 81.3 89.7 ns <0.001
Differences between patients’ model , physician models, and physician beliefs about the patients’ models
Associations With Better Physician Understanding*
Greater Patient Participation◦Meaning, Control, Alternative Treatments,
Relationship (p = 0.01-0.05)Race Concordance
◦Control (p = 0.02)Lower Patient Education
◦Control (p = 0.008)Male Physician
◦Control, Relationship (p = 0.004, 0.05)*Lower absolute difference between
patient own and physician understanding score
Association With Poorer Physician Understanding*
African American Patients (compared w/ Caucasian)◦Relationship (p = 0.02)
Hispanic patients (compared with Caucasian)◦Meaning (p = O.06)
*Greater absolute difference between patient own and physician understanding score
ConclusionSignificant gaps in physician
understanding of patient perspectives in routine primary care settings
Certain demographic factors may impact physician understanding
Active patient participation improved understanding in multiple domains
Questions?
References Epstein RM, Street RL, Jr. Patient-Centered Communication in Cancer
Care: Promoting Healing and Reducing Suffering. Bethesda, MD: National Cancer Institute; 2007. Report No.: NIH Publication No. 07-6225.
P. Haidet, K.J. O’Malley, B.F. Sharf, A.P. Gladney, A.J. Greisinger, & R.L. Street Jr. (2008) Characterizing explanatory models of illness in healthcare: Development and validation of the CONNECT instrument. Patient Education and Counseling, 73, 232-239.
Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27:S110-S127.
Street, R. L., Jr. (2001). Active patients as powerful communicators. In W. P. Robinson, & H. Giles (Eds.), The new handbook of language and social psychology (pp.541-560). New York: John Wiley & Sons.
R.L. Street, Jr., C. Slee, D. K. Kalauokalani, D.E. Dean, D. J. Tancredi, & R. L. Kravitz (2010) press) Improving physician-patient communication about cancer pain with a tailored education-coaching intervention. Patient Education and Counseling, 80, 42-47.
M.M. Ward, S. Sundaramurthy, D. Lotstein, T. Bush, C.M. Neuwelt, & R.L. Street, Jr. (2003). Participatory patient-physician communication and morbidity in patients with systemic lupus erythematosus. Arthritis & Rheumatism, 49, 810-818.
HS Gordon, RL Street, Jr., BF Sharf, & J Souchek. (2006) Racial differences in doctors’ information-giving and patients’ participation. Cancer, 106, 1313-1320.
Street, R. L., Jr. (2001). Active patients as powerful communicators. In W. P. Robinson, & H. Giles (Eds.), The new handbook of language and social psychology (pp.541-560). New York: John Wiley & Sons.
R.L. Street, Jr, M.N. Richardson, V. Cox, and M.E. Suarez Almazor. (2009) (Mis)Understanding in patient-health care provider communication about total knee replacement. Arthritis Care and Research, 61, 100-107.