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Patient-Focused Care^*

Using the Right Tools

^* From the Pulmonary, Allergy and Critical Care Medicine Division (Dr. Irwin), University of Massachusetts Medical School, Worcester, MA; and Magenta Communications (Ms. Richardson), Ltd. Oxon, UK.

Correspondence to: Richard S. Irwin, MD, FCCP, Pulmonary, Allergy and Critical Care Medicine Division, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655; e-mail: Irwinr{at}ummhc.org

	Abstract

TOP Abstract Introduction Patient Preferences for a... Barriers to Patient-Focused Care Influencing Outcomes With... Participant Feedback and... Conclusion References

 
Patient-focused or patient-centered care is not a new concept, but its value has been overlooked in preference to the technology-based, disease-centered model that has prevailed in medicine for the last 50 years. Patient-focused care includes four broad areas of intervention: communication with patients, partnerships, health promotion, and physical care (medications and treatments). We can conceptualize patient-focused care as being the care we would like our loved ones to receive. There is considerable evidence that patients prefer a patient-focused approach. Unfortunately, there are also many studies detailing physicians’ disconnection with patients’ needs, particularly the need for information, and misunderstandings and assumptions based on poor communication. However, it is possible to develop physicians’ skills in patient-focused care and provide physicians with the tools to overcome the barriers to this approach. The patient-focused approach has been shown to improve physicians’ performance, patient satisfaction, and health outcomes without requiring additional investment in time or resources. Patient-focused care has also been shown to improve adherence to medication/advice, a well-known problem in asthma. There are also benefits to the physician in terms of improved outcomes for their patients, higher patient retention, and potentially a reduced risk of litigation. Patient-focused care may be a particularly valuable approach for the management of "difficult-to-treat" patients. In summary, the "three Cs" of patient-focused care—communication, continuity of care, and concordance (finding common ground)—are highly relevant to the effective treatment of pulmonary disease and should be a key component of asthma management.

Key Words: asthma • asthma management • patient-centered care • patient-focused care • physician-patient relationship

	Introduction

TOP Abstract Introduction Patient Preferences for a... Barriers to Patient-Focused Care Influencing Outcomes With... Participant Feedback and... Conclusion References

 
Patient-focused or patient-centered care is not a new concept, but its value has been overlooked in preference to the physician-led, technology-based, disease-centered model that has prevailed in medicine for the last 50 years. Stewart¹ suggests that patient-focused care is often defined by what it is not: technology centered, doctor centered, hospital centered, and disease centered. Today, patient-focused care can be thought of as a merging of the patient education, self-care, and evidence-based models of medical practice.²³ Patient-focused care takes the best points from each of these models and distills them into four broad areas of intervention: communication with patients, partnerships, health promotion, and physical care (medications and treatments).²³⁴ Patient-focused care, therefore, requires an appreciation of a variety of issues: patients’ expectations, beliefs, and concerns regarding their disease and an understanding of their personal circumstances; the motivation to provide information regarding diagnosis, pathology, treatments, and prognosis; the ability to find a common ground on what the problem is and agreeing on management; and the knowledge to utilize the best medical evidence to inform treatment decisions.¹²³

The relative importance of different areas of patient-focused care and how they can be enacted have been debated. Also, clear distinctions have been made between "partnership" and "shared decision making"—the latter being one approach of many to achieving the former.¹ Putting aside semantic debates on the definition of patient-focused care, it is perhaps easier to conceptualize it as being the care we would like our loved ones to receive.³ This article reviews some of the evidence to support patient preferences for patient-focused care, examines the reasons that might have impaired the widespread teaching and adoption of this approach, and outlines some of the potential benefits of patient-focused care for both physicians and patients, with particular reference to asthma management.

	Patient Preferences for a Patient-Focused Approach

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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.¹

Do patients want patient-focused care? Little et al⁴ investigated patients’ preferences for a patient-focused approach in the primary care consultation. These investigators⁴ administered a preconsultation questionnaire to 824 patients, 661 of whom also completed a postconsultation questionnaire.⁴ 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). Most patients agreed that all three aspects of patient-focused care were required; 88 to 99% agreed on the need for good communication, 77 to 87% agreed for partnership, and 85 to 89% agreed for health promotion.⁴ Patients who agreed strongly that they wanted good communication or partnership were likely to feel particularly unwell, attend their doctors’ clinic more regularly, and not be in paid employment. In addition, patients who wanted good communication were less likely to be > 60 years of age.⁴ Patients wanting health promotion attended their doctors’ clinic more regularly and were worried about their problem.⁴ Overall, most patients preferred a patient-focused approach, although it appeared to be even more important to patients who were more vulnerable either due to their illness, their worries, or their socioeconomic situation.

Further evidence to support patients’ preference for a patient-focused approach is provided by an observational study of 2,881 patients visiting 138 family physicians.⁵ Using direct observation and statistical cluster analysis, the investigators⁵ identified four different physician approaches to the consultation interaction: person focused (49%), biopsychosocial (16%), biomedical (20%), and high physician control (14%). Person-focused physicians concentrated more on the person than the disease, were personable and friendly, were open to the patients’ agenda and negotiated options with patients. Biopsychosocial physicians were more focused on the patients’ disease but elicited psychosocial information. Biomedical 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.⁵ 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.⁵ 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.⁵

Patient-focused care, however, is not necessarily the same as physician/patient shared decision making.⁶ Patient preferences for a shared decision-making approach or physician-directed consultations were evaluated using patient responses to videos of acted consultations of these two different approaches.⁷ 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.⁷ 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.

	Barriers to Patient-Focused Care

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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.

Dissociation in Perception of Needs
One of the most fundamental prerequisites for patient-focused care is agreement between patients and physicians on patients’ needs. In a survey-based study, Laine et al⁸ found that physicians (74 general internists) and patients (n = 814) scored the following aspects of outpatient care as similarly important: interpersonal skill, office support staff, patient involvement, coordination of care, and office environment. However, the greatest discrepancy was reported for provision of information: patients found this factor far more important than physicians (p < 0.001), and ranked it second vs sixth for physicians.⁸ If physicians are underestimating patients’ needs for information, this implies that the quality of the consultation for the patient is likely to be adversely effected.

Similar observations were made in a study⁹ of unmet needs as assessed by parents of children with chronic medical conditions, including pulmonary conditions. Parents of 119 children and their physicians from five pediatric practice groups completed surveys regarding the type and level of unmet needs for the children.⁹ These needs were organized into four subgroups: information needs, contact needs, counseling needs, and specific help needs. There 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).⁹ Thus, there was a disconnect between the parents’ perception of their needs and the physicians’ perception.⁹

When considering patients with pulmonary disease specifically, there is evidence that their information needs are not being adequately met by their primary care or specialist physicians. Koning et al¹⁰ surveyed 121 patients with asthma or COPD as to the medical care provided by either their primary care practitioner or their specialist. Although 90% of patients were satisfied with their treatment, the main area expressed by patients as an unfulfilled need was information.¹⁰ A need for more written information about pulmonary illness in general was expressed by 52% of patients. In addition, many patients required more information (verbal or written) regarding diagnostic tests (48%), the causes of their illness (44%), prognosis (34%), and long-term medication use (31%) [Table 2 ].¹⁰ In general, with regard to information, more patients had unmet needs under specialists’ care than for primary care physicians, with a particular discrepancy between the two groups for information on long-term medication.¹⁰ Approximately one third of patients would have liked more participation in decisions about their treatment.

Communication Barriers
Quality communication between physicians and patients is also necessary for patient-focused care, but this can be difficult to achieve in the limited time available for consultation and if patients’ needs are complex. It is important for physicians to realize that many factors may be brought into the consultation, not just the presenting symptoms. An interesting study by Kravitz et al¹² evaluated the expectations of 688 patients prior to and after their visit to an internist’s office. Following the visit, there were 125 patients (18.2%) who had unmet expectations related to physician preparation for the visit (23.2%), history taking (26.4%), physical examination (29.6%), diagnostic testing (28.0%), referral to specialists (26.4%), prescription of medication (19.2%), and physician/patient communication (15.2%). The framework for patients’ perception of unmet expectations was complex and determined by their current somatic symptoms (74%), perceived vulnerability to illness (50%), past experiences with similar illnesses (42%), and knowledge acquired from physicians, family, friends, or the media (54%).¹² This study¹² illustrates that patients’ expectations may not be explicit and need to be actively sought in order for them to be addressed, either by meeting them or by negotiation.

Levenstein et al¹³ 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 al¹⁴ 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.¹⁴ The frequency of voiced vs unvoiced agenda items is shown in Figure 1 .¹⁴ Most of the unvoiced agenda items were psychosocial, but some patients failed to mention symptoms and other biomedical information.¹⁴ This failure to recognize or to coax agendas from patients was not without consequences. Fourteen of the 35 consultations had problem outcomes, and at least one of the problems for each of these consultations was related to an unvoiced agenda item (eg, unwanted prescriptions, nonuse of prescriptions and nonadherence to treatment).¹⁴ Patients may not be comfortable voicing their agendas for a number of reasons; they may feel intimidated, fear that they are not showing respect by questioning diagnoses or medication, or feel that their opinions are not valued in the consultation. They may also not want to be seen as malingering or as being "neurotic" about their health. Therefore, physicians need to cultivate an open, nonjudgmental approach, and actively seek patients’ agendas. This may increase consultation time in the short term, but may improve patient satisfaction, health outcomes, and reduce resource use in the longer term.

View larger version (21K): [in this window] [in a new window] [Download PPT slide]   Figure 1. The discrepancy between patients’ voiced and unvoiced agendas in primary care consultations. Adapted from Barry et al.14

	Influencing Outcomes With Patient-Focused Care

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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 study¹⁵ 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 authors¹⁵ 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.

Stewart et al¹⁶ investigated patient-determined and observer-determined evaluations of patient centeredness on health outcomes. The investigators¹⁶ developed a scoring system to allow observers to evaluate physicians’ patient centeredness in relation to communication. This included exploration of both the patients’ disease and their experience of illness (their feelings, beliefs, impact on functioning, and expectations), understanding of the whole person, and the finding of common ground regarding management.¹⁶ This scoring system and patients’ perceptions of the patient centeredness of their consultation were used to evaluate consultations between 39 family physicians and 315 patients. There was no relationship between the patient-centeredness score and any of the health outcomes evaluated (patients’ level of discomfort, diagnostic tests ordered, and referrals). However, patients’ evaluation of patient centeredness was associated with a lower postencounter level of concern (p = 0.02) as well as improvements 2 months after the consultation in the patients’ level of discomfort (p = 0.03) and their mental health assessment (p = 0.05). These results suggest that patients’ perceptions of quality in health care are relevant to health outcomes.¹⁶ In addition, patient-assessed patient centeredness was associated with fewer diagnostic tests (p = 0.05) and fewer referrals (p = 0.01) in the 2 months subsequent to the visit, indicating that patient-focused care does not equal more interventions and expense.¹⁶

In 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 al¹⁷ 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.¹⁸ 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.¹⁷ Program physicians were more likely to provide written plans and guidance to patients and to have a protocol to track the patient education provided. In addition, parents’ views of physicians’ behavior was significantly improved vs controls (Fig 3 ).¹⁷ The number of hospital admissions was significantly reduced in the program group (effect estimate, – 1.3, p = 0.03), and there was a nonsignificant decrease in emergency department visits, scheduled visits, and follow-up visits. There was no significant difference between program physicians and control subjects in the amount of time spent with patients (25.9 min and 29.0 min, respectively).¹⁷ An updated analysis of this study indicated that children from low-income families ($20,000/annum) had improved asthma outcomes, with a reduction in emergency department visits (p = 0.001) and asthma hospitalizations (p < 0.001) vs a low-income control group.¹⁹ This is a key study, as it shows that it is possible to develop physicians’ skills in patient-focused care and provide them with the tools to overcome the barriers to this approach. This study also demonstrated that a patient-focused approach improved the management of asthma patients, parents’ view of physicians’ performance, and health outcomes without requiring more time for consultations or more scheduled visits or follow ups.

View larger version (22K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Physician education in communication and teaching skills has a positive impact on physician behavior in asthma management. Adapted from Clark et al.17

View larger version (26K): [in this window] [in a new window] [Download PPT slide]   Figure 3. The net estimate of effect of the impact of physician education in communication and teaching skills on parents’ perception of physician behavior in asthma management vs a control group. There was a net improvement in all measures for the intervention, all of which except ‘spends enough time with us’ was statistically significant. Adapted from Clark et al.17

Physician Benefits: Patient Retention and Malpractice Litigation
Patient-focused care may also have objective benefits for the physician. In a longitudinal, observational study²³ of 4,108 patients, 20% voluntarily disenrolled from their primary care physician’s practice over a 3-year period. The quality of the physician/patient interaction predicted patients’ loyalty, with eight factors significantly predicting patient disenrollment (p < 0.001): trust, interpersonal treatment, physician knowledge of patient, communication, access to care, integration, visit-based continuity, and relationship duration. In a multivariate analysis, patients with the poorest quality physician/patient relationship were three times more likely to leave the practice over the 3-year period vs those with the highest quality relationships.²³ Therefore, physicians that are able to develop better relationships with their patients are more likely to retain them, an important economic consideration in many health-care systems.

Not all adverse medical outcomes lead to malpractice litigation, and not all malpractice litigation is triggered by an adverse outcome, so why do patients and families sue doctors and hospitals? One study tried to address this question by looking at discovery depositions in 67 cases of malpractice against a metropolitan medical center.²⁴ This 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.²⁴ 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.²⁴ 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.²⁴

The importance of the physician/patient relationship in determining patient willingness to sue has also been demonstrated in other studies. A report²⁵ by the American College of Obstetrics and Gynecology based on 59 primary care physicians examined patient consultations for physicians who had never been named in a malpractice claim vs those with two or more claims against them. In a multivariate analysis, "no-claims" physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, used more facilitation (soliciting patients’ opinions, checking understanding, and encouraging patients to talk), and spent longer times in routine visits (mean, 18.3 min vs 15.0 min; difference not significant) compared with physicians who had been named in claims.²⁵ Therefore, routine physician/patient communication was different between doctors without claims vs those that had been sued for malpractice.²⁵ Thus, with regard to malpractice avoidance, communicating effectively with patients may be a physician’s best defense.

Difficult-To-Treat Patients
Patient-focused care may have a particular role to play in the management of difficult-to-treat patients. These patients may have more complex needs because of their disease severity and/or social and economic factors. Evaluating these more complex needs and meeting them may require specialist services and training. However, it also requires the development of long and positive relationships between clients and service providers.

The effectiveness of this approach has been demonstrated in the development of an asthma center specifically developed to target patients with difficult-to-control asthma.²⁶²⁷ Adult patients with more than two emergency department visits within the last 6 months were referred by their primary care provider.²⁶ Interventions included an initial evaluation by asthma center personnel, spirometry and skin allergy testing, the development of treatment and follow-up plans after discussion of the patient by team members, extensive patient education, and establishment of a relationship with one of the asthma center nurses and physicians. Statistical analysis was not presented in this abstract report, but some of the results have obvious clinical and economic relevance. An analysis of 125 patients found that 90% rated their visit to the asthma center "very good" or "excellent."²⁶ Based on prescriptions filled, there was a reduction in the ratio of ß-agonist use vs inhaled corticosteroid use (ratio of 1.65 before vs 1.05 after). Most importantly, there was a decrease with intervention in the number of emergency department visits from 74 to 17 (76% reduction) and the number of hospitalizations from 38 to 4 (89% reduction). These were translated into a reduction in costs of emergency department visits from $34,706 to $7,973, and of inpatient care from $192,926 to $20,309; a total saving of $199,351. In comparison, the cost of the initial visit to the asthma center was $770.²⁶ A update²⁷ on the program presented further benefits (also no statistical analysis provided). There was a clinically relevant improvement in quality of life from an Asthma Quality of Life Questionnaire score of 3.8 to 5.0 after 6 months in the program²⁷ (a score of 7 is normal, and a change of at least 1 represents a clinically noticeable moderate change).²⁸ In addition, patients receiving inhaled corticosteroids increased from 72% at baseline to 82% after 6 months.²⁷ Baseline compliance was 66%, and this increased to 87% after 6 months. At baseline, no patients used an action plan vs 100% after 6 months.²⁷ This study demonstrates that a patient-focused approach where time is spent developing relationships, organizing treatment plans and follow-up, and educating patients can improve medical outcomes and costs for patients with asthma who are the most challenging to manage.

	Participant Feedback and Discussion

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Among other points, the workshop participants discussed the following: • How do we address concerns about adverse events with our patients? • Do you counsel patients by agreeing on a plan of action (concordance)? • What are the potential barriers to patient-focused care?

Participants highlighted a number of points that they believed formed the basis of patient-focused care (Table 3 ). Patients are more likely to be motivated to follow treatment advice if they perceive the recommendations to be a common sense approach to maintaining health, and if they have a clear appreciation of the nature of their illness and an understanding of treatment risks and benefits. It is also important to consider that the management of chronic disease differs from that of an acute illness, so clinicians must be prepared to work in an ongoing partnership with patients to ensure that they are offered a clear rationale as to why inhaled corticosteroids are necessary, and to address their concerns about potential adverse effects. This approach, the basis of which is a detailed examination of patients’ perspectives on asthma and its treatment, and an open, nonjudgmental manner on the part of the clinician, is consistent with the idea of concordance. It also fits in with other recent initiatives, such as the "expert patient," and shared decision making. The challenge for clinicians is to ensure that the best-available information is communicated clearly to the patient, not so much to enhance adherence but, rather, to allow patients to make an informed decision that is not based on an erroneous set of beliefs. The partnership will be flawed if patients feel they are wasting their doctors’ time, if they feel they have not been listened to, or if they choose to not share certain key information; the consultation may not be concordant. To some extent, the ways in which asthma and ICS are viewed by patients also require "updating" to correct mistaken public prototypes and stereotypes of the condition. Even today, patients may view asthma as a stigma (eg, when using inhalers in public), and dealing with its potentially negative social image can be troublesome for children and adolescents.

	Conclusion

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Asthma is a complex disease that in many instances affects patients throughout their lives. The three Cs of patient-focused care—communication, continuity of care, and concordance (finding common ground)—are highly relevant to the effective treatment of pulmonary disease and should be a key component of asthma management.

	Footnotes

 
Dr. Irwin has no potential personal or financial conflict of interest to disclose. N.D. Richardson discloses that she was contracted to provide author support on manuscript preparation by BoomCom Communications, Inc., Denver, CO. BoomCom Communications, Inc., was engaged by Altana Pharma, the sponsor of the supplement.

Received for publication July 2, 2006. Accepted for publication March 20, 2006.

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