The Quality of Physician-Patient Relationships

,

Original Research

The Quality of Physician-Patient Relationships

J Fam Pract. 2001 February;50(2):123-129

References

1 Greenfield S, Kaplan SH, Ware JE, Yano EM, Frank HJL. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448-57.

2. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med 1985;102:520-28.

3. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27 (suppl):S110-27.

4. DiMatteo MR. Enhancing patient adherence to medical recommondations. JAMA 1994;271:79-83.

5. Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient communication: patients’ response to medical advice. N Engl J Med 1969;280:535-40.

6. Penchansky R, Macnee C. Initiation of medical malpractice suits: a conceptualization and test. Med Care 1994;32:813-31.

7. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med 1994;154:1365-70.

8. Harpole LH, Orav J, Hickey M, Posther KE, Brennan TA. Patient satisfaction in the ambulatory setting: influence of data collection methods and sociodemographic factors. J Gen Intern Med 1996;11:431-34.

9. Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care 1998;36:728-39.

10. Institute of Medicine Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.

11. Dillman DA. Mail and telephone surveys: the total design method. New York, NY: John Wiley; 1978.

12. Ware JE, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability. Med Care 1996;34:220-33.

13. National Center for Health Statistics. Current estimates from the National Health Interview Survey. Washington, DC: US Government; 1993.

14. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-29.

15. Emanuel EJ, Brett AS. Managed competition and the patient-physician relationship. N Engl J Med 1993;329:879-82.

16. Ettner S. The relationship between continuity of care and the health behaviors of patients: does having a usual physician make a difference? Med Care 1999;37:547-55.

17. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients’ trust in their physicians: effects of choice, continuity, and payment method. J Gen Intern Med 1998;13:681-86.

18. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract 1997;45:129-35.

19. Weiss LJ, Blustein J. Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans. Am J Public Health 1996;86:1742-47.

20. Hjortadahl P. Continuity of care: general practitioners’ knowledge about, and sense of responsibiltiy toward their patients. Fam Pract 1992;9:3-8.

21. Weiss GL. Patient satisfaction with primary medical care. Med Care 1988;26:383-92.

22. Becker MH, Drachman RH, Kirscht JP. A field experiment to evaluate various outcomes of continuity of physician care. Am J Public Health 1974;64:1062-70.

23. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston, Mass: New England Medical Center; 1993.

24. DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol 1993;12:93-102.

25. Marquis MS, Davies AR, Ware JE. Patient satisfaction and change in medical care provider: a longitudinal study. Med Care 1983;21:821-29.

26. Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA 1999;282:261-66.

27. Safran DG, Murray A, Chang H, Montgomery J, Murphy J, Rogers WH. Linking doctor-patient relationship quality to outcomes. J Gen Intern Med 2000;15(suppl):116.-

28. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality of care. Inquiry 1988;25:25-36.

29. Robbins JA, Bertakis KD, Helms LJ, Azari R, Callahan EJ, Creten DA. The influence of physician practice behaviors on patient satisfaction. Fam Med 1993;25:17-20.

30. Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract 1997;44:169-76.

31. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84.

32. Carney QA, Eliassen MS, Wolford GL, Owen M, Badger LW, Dietrich AJ. How physician communication influences recognition of depression in primary care. J Fam Pract 1999;48:958-64.

33. Wagner EH, Barrett P, Barry MJ, Barlow W, Fowler FJ. The effect of a shared decisionmaking program on rates of surgery for benign prostatic hyperplasia. Med Care 1995;33:765-70.

34. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE. Characteristics of physicians with participatory decision-making styles. Ann Intern Med 1996;124:497-504.

35. Palmer RH. Considerations in defining quality of health care. Part I. In: Palmer RH, Donabedian A, Povar GJ, eds. Striving for quality in health care: an inquiry into policy and practice. Ann Arbor, Mich: Health Administration Press; 1991:1-54.

36. Harris LE, Swindle RW, Mungai SM, Weinberger M, Tierney WM. Measuring patient satisfaction for quality improvement. Med Care 1999;37:1207-13.

37. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583-89.

38. Fox SA, Stein JA. The effect of physician-patient communication on mammography utilization by different ethnic groups. Med Care 1991;29:1065-82.

39. Taira DA, Safran DG, Seto TB, Rogers WH, Tarlov AR. The relationship between patient income and physician discussion of health risk behaviors. JAMA 1997;278:1412-17.

40. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Mahwah, NJ: Lawrence Earlbaum; 1988.

Follow-up data were collected between January and April 1999. The follow-up questionnaire was administered to all baseline study participants who had identified a primary care physician and whose physician was listed in the Massachusetts Board of Registration in Medicine registry of licensed physicians (n=6075). Follow-up data collection employed a 3-step mail survey protocol as at baseline and was supplemented with final targeted mailings to 2 groups of nonrespondents (ethnic minorities, n=31, and those without a college diploma, n=521). The targeted mailings were performed, when nearing the conclusion of data collection, these subgroups were found to be under-represented among follow-up respondents. Completed questionnaires were received from 69.4% of the eligible respondents at follow-up (n=4108). Data collection and entry at baseline and follow-up were managed by the Center for Survey Research, University of Massachusetts (Boston).

In addition to the PCAS measures, the baseline and follow-up questionnaires were used to ascertain the respondents’ sociodemographic profiles (age, sex, race, years of education, household income) and health status. Measures of health status included the Medical Outcomes Study Short Form-12 (SF-12) Health Survey¹² and a checklist of 20 chronic conditions with high prevalence among US adults.¹³

Statistical Analyses

The principal analytic objective was to study the changes in primary care experiences of patients in a sustained primary care relationship during the 3-year study period. Patients who had changed physicians were excluded from the analytic sample. By restricting our analyses to patients who remained with the same physician we were able to isolate changes in their care over the 3-year study period without confounding factors associated with changing physicians. The analytic sample included patients who completed both the baseline and follow-up questionnaires, who identified a primary physician at baseline, and who remained with that physician throughout the 3-year study period (n=2383).

In a comparison of baseline characteristics of 1996 baseline respondents (n=6810) and those who were retained at the 3-year follow-up period (n=4108), the 1999 respondents were on average a year older (49 vs 48 years). They were more likely to be women (57% vs 55%) and more likely to be white (89% vs 86%). Education and income levels and measures of mental and physical health were almost equal in 1996 and 1999.

After exclusions, baseline demographics and health indexes of the analytic sample still remained near equal to those of the overall 1999 respondent group. Members of the analytic sample were more likely to be women (57% vs 55%) and to have a baseline primary care physician relationship duration of more than 5 years (54% vs 49.6%) when compared with the overall 1999 respondents. Compared with respondents, nonrespondents were younger, more likely to be men, poorer, less educated, and of a racial group other than white.

Baseline characteristics of physicians of 1999 respondents were also examined. The specialties of physicians were listed in the Massachusetts Board of Registration as 19% family physicians, 65% internists, 3% obstetrician-gynecologists, 4% cardiologists, and another 9% spread across other specialties. The physicians of patients in our analytic sample had the same specialty group distribution as the overall sample. In comparison with the overall group of 1999 respondents’ physicians, the physicians of the analytic sample were more likely to be men (80% vs 75%) and earlier graduates. Differences are due in part to patients nominating residents in training programs as their primary care physicians (6% of the overall respondent sample, 0% of the analytic sample). These patients subsequently changed their primary care physicians and were not included in the analytic sample. Also, there is an under-representation of women in the older group of physicians who have stable long-term relationships with their patients.

For each patient, we computed the difference between the 1996 and 1999 scores on each of the 8 PCAS scales (quality of communication, interpersonal treatment, physician’s knowledge of the patient, patient trust, financial access, organizational access, visit-based continuity, integration of care). We determined the unadjusted mean change in each scale and the 95% confidence interval around this change. To permit comparison across scales, we computed a standardized difference score (the effect size), which was the mean change of scales divided by the standard deviation of the referent scale scores at baseline.

Because previous empiric medical literature,^14,15 other research,^16-22 and our own cross-sectional data from baseline suggested that physician-patient relationship quality improves with increased relationship duration, we also examined the changes in indexes of relationship quality, controlling for the increased relationship length that occurred during our study for the group of patients who did not switch physicians. The adjusted changes in the relationship quality scales of communication, interpersonal treatment, physician knowledge of the patient, and trust were calculated using regression models. We used the longitudinal data in a stacked data set in which each patient’s pair of observation sets (from 1996 and 1999) was entered and included a binary variable indicating the survey round (round 1=0 and round 2=1). The stacked data make possible regression of the scale scores for each of the 4 indicators of relationship quality against a measure of relationship length, which (inherent in the selection criteria for the analytic sample) increased from the first to the second round of the survey. Inclusion of the survey round indicator in the 4 relevant regressions allowed a regression coefficient to be obtained for each scale, which reflected the magnitude of average difference in scale scores over the study period, adjusting by increases in the length of physician-patient relationship. P values for these regressions were used to evaluate the significance of the findings.