Free and paid medical assistance in the United States News : Part 8

Patient-Focused Care: Physician Benefits: Difficult-To-Treat Patients

Patient-Focused Care: Physician Benefits: Difficult-To-Treat PatientsThis study was a qualitative retrospective assessment of depositions and indicated that the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of healthcare. Problematic relationship issues between the doctor and patient were identified in 71% of the depositions. These could be categorized by four themes: deserting the patient (32%), devaluing patient and/or family views (29%), delivering information poorly (26%), and failing to understand the patient and/or family perspective (13%). The postoutcome consulting specialist was named in 71% of the depositions in which malpractice was alleged. These results imply that if more attention had been focused on the physician/patient interaction, particularly at the postoutcome consultation, litigation could have been avoided in many of these cases. this

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Patient-Focused Care: Physician Benefits: Patient Retention and Malpractice Litigation

Pulmonary disease has one of the lowest levels of patient adherence for any area of medicine. In a meta-analysis of 569 studies, pulmonary disease ranked fifteenth out of 17 different disease conditions for adherence, with a mean adherence rate of 68.8%. Only diabetes (67.5%) and sleep disorders (65.5%) ranked worse. Adherence is discussed in detail elsewhere in this Supplement (see the article by Horne). However, as an example of the importance of patient-focused care to adherence, it is worth mentioning that in the Medical Outcomes Study, general adherence and adherence to medication, exercise, and diet recommendations in diabetic, hypertensive, and heart disease patients were related to the following: physician job satisfaction (general adherence), number of patients seen per week (medication), scheduling a follow-up appointment (medication), tendency to answer patients’ questions (exercise), number of tests ordered (diet), seriousness of illness (diet), physician specialty (medication, diet), and patient health distress (medication, exercise). All of these factors, except physician specialty and seriousness of illness, can be influenced within the framework of patient-focused care.

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Patient-Focused Care: Adherence

Patient-Focused Care: AdherenceIn asthma, there is evidence that a patient-focused approach can be learned and applied to improve both parents’ view of physicians’ behavior and health outcomes. Clark et al evaluated the long-term impact of an interactive physician seminar based on the principles of patient self-regulation, clinician behavior, children’s use of asthma services, and parents’ evaluations of physician performance. The seminar focused on the development of physician communication and teaching skills, and used the therapeutic recommendations from the National Asthma Education and Prevention Program guidelines. Follow-up assessment of 34 physicians completing the program and 33 control subjects was accomplished by self-administered surveys, telephone interviews with parents of their patients, and review of patients’ medical records. Figure 2 shows the impact of the education program on physician behavior approximately 2 years after intervention. fully

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Patient-Focused Care: Patient Satisfaction and Health Outcomes

The effect of patient centeredness and a positive approach on patient satisfaction and health outcomes was evaluated in a UK study of 661 patients who completed a postconsultation questionnaire. The goals of the study were to determine the importance of patient centeredness to patient satisfaction, patient enablement, and symptom burden 1 month after the consultation. Independent predictors of high patient satisfaction were communication and partnership (p < 0.001) and a positive approach from the physician (p < 0.001). High patient enablement was independently predicted by the patients’ perception of the doctors’ interest in the effect of the problem on their lives (p = 0.001), health promotion (p < 0.001), and a positive approach (p < 0.001). At 1 month after consultation, patient-assessed symptom burden was improved with a positive approach (p = 0.004). The authors concluded that patients want a patient-centered, positive approach, and if they receive this approach they are more satisfied, have greater enablement, and have greater improvement in their symptom burden. sildenafil citrate pink

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Patient-Focused Care: Influencing Outcomes With Patient-Focused Care

Patient-Focused Care: Influencing Outcomes With Patient-Focused CareLevenstein et al introduced the concept of a “patient agenda” as playing a pivotal role in physician understanding. The physician’s agenda is the explanation of the patient’s illness in terms of a taxonomy of disease and prescription of treatment as necessary. In a disease-centered model, only this agenda is addressed. However, in a patient-focused model, the patient’s agenda should be elicited and addressed as well. Patients may not actively voice their agendas, and the physician needs to be receptive to cues from patients and to enact behavior that encourages them to express their feelings, beliefs, and concerns. However, physicians are not always skilled in eliciting patients’ agendas. For example, Barry et al interviewed 35 patients prior to a primary care consultation to determine their agendas and evaluated the consultation as to whether the patients’ agendas were actually voiced. There was a total of 188 agenda items expressed in the preconsultation interviews, 73 of which were unvoiced during the interview (38.8%). All patients had more than one agenda item, and most had five or more items, and only four patients (11.4%) voiced all of their agenda items. The frequency of voiced vs unvoiced agenda items is shown in Figure 1. Most of the unvoiced agenda items were psychosocial, but some patients failed to mention symptoms and other biomedical information. canadian health&care mall

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Patient-Focused Care: Communication Barriers

Multilinear regression models were used to assess the impact of age, sex, race, education, number of physician visits, health improvement and life satisfaction, and continuity of care on provider communication (“The doctor or provider listened to you and talked with you about your care”) and level of patient influence (“Your ability to influence the treatment you received from a doctor or provider for your health problems”). For asthmatic patients, the quality of provider communication was only dependent on continuity of care (p = 0.01). Continuity of care (p = 0.02) and life satisfaction (p = 0.04) were the only variables contributing to the level of patient influence for asthmatic patients. For nonasthmatic patients, continuity of care, age, number of physician visits, general health, health improvement, and life satisfaction all contributed to patients’ perceptions of quality for provider communication (p < 0.01); these variables also contributed significantly to patient influence (p < 0.008). read only

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Patient-Focused Care: Medical Care

Patient-Focused Care: Medical CareThere was a high level of agreement between mothers and fathers on the number of needs for all of the subgroups, although there was a significant difference for contact needs, where only mothers, not fathers, perceived a higher need to be in contact with parents of children in a similar situation to themselves (p < 0.01). Physicians’ ratings of information needs showed very poor correlation with either mothers’ (r = 0.7) or fathers’ (r = — 0.01) ratings, with physicians significantly underestimating the number of information needs (p < 0.05). Physicians also noted significantly fewer needs for specific help than either mothers (p < 0.01) or fathers (p < 0.001) and fewer contact needs than mothers (p < 0.01). Overall, both mothers and fathers endorsed a greater total number of needs than physicians (p < 0.001). Thus, there was a disconnect between the parents’ perception of their needs and the physicians’ perception.

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Patient-Focused Care: Barriers to Patient-Focused Care

Patient-focused care, however, is not necessarily the same as physician/patient shared decision mak-ing. Patient preferences for a shared decisionmaking approach or physician-directed consultations were evaluated using patient responses to videos of acted consultations of these two different approach-es. Preference for a directed approach was seen when the illness involved physical rather than psychological symptoms and in subjects > 61 years of age. Preference for a shared approach was associated with higher social class (professional and managerial/ technical) and with subjects who smoked. There were, however, large minorities in these groups favoring the opposite approach. It appears that shared decision making is a distinct entity from patient-focused care, and physicians need to understand their patients’ level of need to be involved in decision making vs being directed and guided at a time when they may feel vulnerable.

If patient-focused care is preferred by most patients, why is it not universally adopted? In clinical practice, there are significant barriers to patient-focused care that need to be overcome.
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Patient-Focused Care: Research

Patient-Focused Care: ResearchBiomedical physicians were more focused on the patients’ disease but were unlikely to elicit psychosocial information. High-control physicians dominated the encounter and disregarded the patients’ agenda. These physician styles were compared with patient-evaluated quality attributes in primary care using the Components of Primary Care Instrument and patient satisfaction. Table 1 shows the rankings for the different physician styles against these outcomes and length of visit. There was a significant difference between the different styles for communication, accumulated knowledge, coordination of care, patient satisfaction with physician, and patient expectations met. The person-focused style was ranked first for all of these factors; biopsychosocial was ranked second for four of the five factors, followed by biomedical; and high physician control was the least effective style, ranked last for four of these five elements. The person-focused style was the style most likely to be associated with a positive assessment of patient-determined quality in primary care and patient satisfaction. However, consultations with the person-focused style were longer than with the other styles, which can be a challenge to disseminate widely in primary care. read

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Patient-Focused Care: Patient Preferences for a Patient-Focused Approach

Patient-focused care aims to bring more equality into the physician/patient relationship as well as an understanding of the patient, not just their illness. However, models of medical management are generally conceived, tested, and disseminated by medical professionals.
Do patients want patient-focused care? Little et al investigated patients’ preferences for a patient-focused approach in the primary care consultation. These investigators administered a preconsultation questionnaire to 824 patients, 661 of whom also completed a postconsultation questionnaire. Factor analysis identified three groupings of patient preferences: communication (including listening, exploration of concerns, and requirements for information, doctor-patient relationship and a clear explanation); partnership (including specific aspects of communication related to finding common ground, such as exploration, discussion, and mutual agreement about patients’ ideas, the problem, and treatment); and health promotion (including how to stay healthy and reduce the risk of future illness). ventolin inhalers

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