MRC policy briefs to government

Interventions for providers to promote a patient-centred approach in clinical consultations. A systematic review

S. A. Lewin,^1,3 Z. C. Skea,² V. Entwistle,2 M. Zwarenstein,3 J. Dick³

¹Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK. Telephone: +44 20 79272102. Facsimile: +44 20 75804524. e-mail: simon.lewin@lshtm.ac.uk
²Health Services Research Unit, University of Aberdeen, UK.
³Health Systems Research Unit, Medical Research Council of South Africa, PO Box 19070, Tygerberg 7505, South Africa. Telephone: +27 (0)21 938 0454. Facsimile: +27 (0)21 938 0483. e-mail: simon.lewin@mrc.ac.za

Background
Communication problems in health care may arise as a result of health care providers focusing on diseases and their management, rather than on people, their lives and their health problems. Patient-centred approaches to care are increasingly advocated by consumers and clinicians and incorporated into training for health care providers, including in South Africa.1-3 The effects of interventions that aim to promote patient-centred care need to be evaluated. A systematic review was carried out to assess the effects of interventions for health care providers that aim to promote patient-centred approaches in clinical consultations.

Main results

Description of studies
Seventeen studies met the inclusion criteria. These studies were heterogeneous in terms of the interventions compared, the health problems or health concerns on which the interventions focused and the outcomes assessed. All used training for health care providers as an element of the intervention. In seven studies training was one component of a multi-faceted intervention. The other components included patient-centred training or materials for patients and condition- or behaviour-specific (i.e. related to a specific health condition such as asthma or hypertension, or behaviour such as smoking) training or materials for providers.

The aims and conceptual bases of the interventions studied varied widely. There was a gradation from interventions in which improving the patient-centredness of care was the primary goal, to others in which patient-centred care was seen mainly as 'instrumental' - a means to improve another health behaviour or outcome. All except three studies could be included in the group in which improving patient-centredness of care was the primary goal. In this latter group of studies, the focus was primarily on encouraging patient behaviour change through negotiating individual care plans and behaviour change targets, and then supporting patients in their choices. One study, which focused on improving general practitioners' detection of psychological problems in their patients after an educational intervention, did not fit into either group.

Most studies focused on primary care physicians practising in community or hospital outpatient settings. In two studies the care providers also included nurses. Only one study appeared to have involved consumers in the development of the intervention. None of the studies appeared to have involved consumers in the delivery of the intervention.

Effects of the interventions
There is fairly strong evidence to suggest that some interventions to promote patient-centred care in clinical consultations may lead to significant increases in the patient-centredness of consultation processes. This is indicated by a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy, etc. Twelve of the fourteen studies that assessed consultation processes showed improvements in some of these outcomes.

There is also some evidence that training health care providers in patient-centred approaches may impact positively on patient satisfaction with care. Of the eleven studies that assessed patient satisfaction, six demonstrated significant differences in favour of the intervention group on one or more measures.

Few studies examined health care behaviour or health status outcomes. The limited and mixed nature of the evidence available means we are as yet unable to reach confident conclusions about the effects on health care behaviours or health status of interventions that encourage health care providers to use patient-centred approaches in consultations.

Conclusions

Implications for practice
There is fairly strong evidence to suggest that some interventions to promote patient-centred care in the clinical consultation may lead to significant increases in the patient-centredness of consultation processes. There is also some evidence that training health care providers in patient-centred approaches may impact positively on patient satisfaction with care.

It is difficult to quantify the benefits/effects of training health care providers in patient-centred care on health care behaviours or health status, and therefore difficult to give recommendations to policy makers and professional bodies regarding investment into the development of such training on the basis of available research evidence. However, if patient-centred care is seen as worthy in its own right, such investment is probably justified because these interventions do seem to lead to significant increases in the patient-centredness of consultation processes.

Implications for research

• Future randomised controlled trials (RCTs) need to focus on assessing the effects of interventions to promote patient-centred care on health care behaviour and health status outcomes. The effects of variations in the intensity of the interventions, in terms of patient- centredness and teaching tactics, also need to be examined.
• Future RCTs should also specifically assess the effects of interventions other than health care provider training, such as changes in the organisation of care, in promoting patient- centred care in the clinical consultation.
• More attention needs to be paid to the methodological quality of RCTs, particularly where cluster randomisation is used.
• A widely acceptable definition of patient-centred care that can be operationalised in effectiveness studies needs to be developed.
• There is currently no 'gold standard' measure for patient-centredness, and this area needs further work in order to develop valid, reliable and appropriate tools to assess the effects of interventions to promote patient-centred care on consultation processes.4
• Ways of involving health care consumers in the design, planning and delivery of interventions to promote patient-centred care need to be explored. In particular, the outcomes assessed in evaluations of interventions to promote patient-centred care should include measures of issues seen as important by consumers for quality of care.

Search strategy for this review
We searched the following electronic databases: Medline (1966 - Dec 1999); Health Star (1975 - Dec 1999); PsycLit (1887 - Dec 1999); Cinahl (1982 - Dec 1999); and Embase (1985-Dec 1999). We also searched the bibliographies of studies assessed for inclusion.

Criteria for considering studies for this review
The review included randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series of interventions for health care providers that promote patient-centred care in clinical consultations. We restricted the review to these study designs so we could produce as unbiased an estimate as possible of the effects of interventions that aim to promote patient-centred approaches in clinical consultations. We treated interventions as intended to increase the patient-centredness of the clinical consultation if they promoted either of two features:

• health care providers share control of the consultation, decisions about interventions or management of the health problems with the patient, and/or
• health care providers focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts. This is in contrast to a focus in the consultation on a body part or disease.

We included studies of interventions directed at any type of health care provider, including those in training, and any type of patient.

Data collection and analysis
Two reviewers independently extracted data and assessed the methodological quality of each study. Outcomes were grouped in the following categories:

• Consultation processes, including the extent to which patient-centred care was judged to be achieved in practice.
• Other health care behaviours, including types of care plans agreed; providers' provision of interventions; patients' adoption of lifestyle behaviours; and patients' use of interventions and
  services.
• Health status and well-being, including physiological measures (e.g. of blood pressure); clinical assessments (e.g. of wound healing); patient self-reports of symptom resolution or quality of life; and patient self-esteem.
• Patient and/or carers' satisfaction with care.

The heterogeneity of the aims, format and content of the interventions; the health care providers and patients involved in the studies; the clinical settings in which the studies were conducted; and the outcomes assessed was substantial. We judged it inappropriate to combine the results of included studies quantitatively, as an overall estimate of effect would have little practical meaning in these circumstances. A descriptive review of the included studies was therefore performed.

Funders
Principal funding for this review was provided by the Health in Partnership initiative of the UK Department of Health (3700512). Additional funding for members of the review team was provided by the Medical Research Council of South Africa; the UK Department for International Development; the Chief Scientist Office of the Scottish Executive Health Department; and the Nuffield Commonwealth Programme.

Acknowledgements
Peer-reviewers: Hilda Bastian, Dominique Broclain and anonymous Consumer and Communication Group reviewers. Statistical advice: Ben Armstrong, Carl Lombard, Graeme MacLennan. The study authors who provided us with additional information regarding study designs and interventions. Sophie Hill and Megan Prictor at the editorial base for the Consumer and Communication Group.

This review should be cited as: Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a patient-centred approach in clinical consultations (Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update Software.

Selected references

1. Henbest RJ, Fehrsen GS. Patient-centredness: is it applicable outside the West? Its measurement and effect on outcomes. Fam Pract 1992; Sept., 9 (3): 311-317.
2. Henbest RJ, Stewart M. Patient-centredness in the consultation. 2: Does it really make a difference? Fam Pract 1990; Mar., 7 (1): 28-33.
3. de Villiers PJ, de Villiers MR. The current status and future needs of education and training in family medicine and primary care in South Africa. Med Educ 1999; Oct., 33 (10): 716-721.
4. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Social Science and Medicine 2000; 51(7): 1087-1110.