Does physician–patient communication that aims at empowering patients improve clinical outcome?: A case study

https://doi.org/10.1016/j.pec.2005.04.009Get rights and content

Abstract

Objective

A case study at the department for heart surgery of an Austrian University Hospital in 2001, examined the outcome of improved communication aimed at empowering patients to be more effective co-producers of recuperation after surgery.

Methods

Evaluated were the effects of a training program for developing communication skills of health professionals (physicians, physiotherapists, and nurses) along with a reorganization of patient information schemes. The clinical outcomes after four types of surgery (bypass, stent, artificial valve insertion and combination of these) were observed in 100 patients without (control group) and 99 with the intervention administered (intervention group). Two objective and two subjective health outcome parameters were selected for analysis: care level adjusted length of stay in hospital, frequency of post-surgery complications, subjective health, subjective satisfaction with care received. Self-administered breathing exercises were measured as an intermediary outcome parameter.

Results

In the intervention group length of hospital stay was shorter (by 1 day), incidence of post-surgery tachyarrhythmia was reduced (by 15%), transfer to less intensive care levels was faster and patient ratings for communicative quality of care by doctors and nurses were improved.

Conclusion

Professional communication aimed at empowering patients to act as co producers can indeed have an effect on clinical outcome.

Practice implications

Staff training and reorganization of communication schemes can be an effective intervention in hospital care.

Introduction

It is generally known from clinical routine, and supported by studies of various designs that better physician–patient communication will have a favourable effect on patient satisfaction and compliance [1], [2], [3], [4], [5], [6], [7]. Physician–patient communication also is generally acknowledged as an important quality factor in treatment processes [7], [8], [9], [10], [11], [12], [13], [14]. But little is known so far about effects of physician–patient communication on subjective and objective health status of patients. Clarification is needed whether these effects are unspecific “context effects” (like the Hawthorne effect in organization research—the effect of any kind of social attention as powerful stimulus for improved group performance), or whether specific aspects of communication, in literature often grouped in emotional aspects (a good interpersonal relationship; physician's demonstrated empathy), the exchange of information (leading to improved information and raised motivation of patients), or others are decisive [7].

In the last years, a concept of the relationship between providers of health care and patients stressing the importance of empowering patients to act more co-productive in treatment processes to improve clinical outcomes broadly has been accepted [15], [16], [17], [18], [19], [20], [21]. At the same time this concept also is questioned. Empowerment may only be a lip-service with a traditional paternalistic attitude and practice behind it [22]. Or empowerment may not be the actual wish of the patients [23]. Or empowerment is better conducted by direct focus on patient behaviour than by improving provider–patient interaction [24].

But patient's co-production in our view refers to the fact that a patient cannot just leave his/her body to the doctor to be repaired but always has to (co-)produce his/her health or recuperation, if he/she wants or not. Therefore, clinical outcome is always the effect of a co-production of clinical interventions by staff and living processes of the patient him/herself. So, for optimal clinical results patients have to actively participate and co-operate in all treatment processes, and they have to be enabled by providers to do that effectively.

Prerequisites for enablement or empowerment of patients seems to be a successful doctor–patient communication that provides adequate information, opportunities for (shared) decision making [25], [26] and motivates and supports the patient to co-operate.

Here, we report on a case study in a heart surgery department in an Austrian University Hospital that introduced a program for communication improvement. Focus of the program was to train staff members to communicate in a more patient centred style. Patient centred communication combines to inform the patient about all aspects of treatment that are relevant for him/her, especially concerning possibilities of his/her active participation in treatment processes (informational quality), and to establish a friendly and supportive relationship (emotional quality of communication).

The study examined two research questions: first, whether a training in skills of patient centred communication for professionals and improvements in patient information talk schemes have effects on objective and subjective clinical outcome parameters. Secondly, how can such effects be explained, as unspecific (a Hawthorne effect), or as specifically related either to the informational or to the emotional quality (relational aspect) of provider–patient communication.

The case study was performed as part of an intervention study with three Austrian Hospitals, funded by the Austrian Ministry of Health, that aimed at examining costs and benefits of improving communication with in-patients. Within the larger intervention study, a joint project group with members from all hospitals discussed and counselled the planning of intervention and evaluation designs, and compared results after the implementation of measures.

The heart surgery department was chosen for this case study, because it had the most consistent approach in reorganising patient information schemes and had a sufficient sample size in the patient survey for statistical analysis as well. Also, heart surgery patients are described as an important group for communication interventions [27], [28], [29], [30], [31], [32] due to their special needs for psychosocial support and for relevant information about treatment and rehabilitation processes.

Section snippets

Methods and sample

The case study included 199 patients who underwent cardiac surgery interventions of one of four standardized types (bypass; insertion of an artificial valve; stent; a combination of these; all patients uniformly received a general anaesthesia). Ninety-nine patients were included in the intervention group after a communication training for staff and a reorganization program aiming at improving physician–patient communication was implemented, 100 patients already had been selected for control

Group differences by age, sex, education, type of surgery

There were 98 patients studied without and 97 with the intervention. Proportion of males was 2/3 in both groups, mean age among male patients was 64.6 (S.D. 11.7) versus 62.1 (S.D. 11.8) years, for females 69.8 (S.D. 10.8) versus 66.6 (S.D. 10.6) for control and intervention group, respectively. General education was measured on a nine-item scale, from dropout of elementary school to university graduate: the variable displayed the same distribution for control and intervention group for both

Discussion and conclusion

With respect to potentially relevant confounders like sex, age, formal education and type of surgery, the intervention, and control group were quite homogeneous. These variables also did not predict the clinical outcome measures.

But the intervention group displayed, compared to the control group, substantial improvements in the two objective measures of clinical outcome—incidence of one major type of complications, namely post-surgery tachyarrhythmia, and care level adjusted duration of stay in

Practice implications

Improved communication with patients in major routine interactions in patient care (admission, round wards, trainings, and discharge) in many cases will lead to better clinical results and higher patient satisfaction, without raising net costs. Therefore, investing into staff training and reorganization of information and communication schemes can be an effective and cost effective intervention in hospital care.

More detailed results of the reported project, including a hands-on description of

Limitations to study

As in many studies that are conducted in the framework of an intervention program that aims at improving practical routines in hospitals, there was no randomisation of samples in this case study. All patients that were admitted at the centre during the two survey periods for elective surgery of defined types and fulfilled the inclusion criteria were included in the study.

The indicator used in this study for informational quality also is of limited validity as it measured only patients’

Acknowledgements

We would like to thank the members of the project team at the participating hospital: Dipl. Physiother. Waltraud Beitzke, Ass. Dr. Peter Bergmann, Stat. Sr. Theresia Donner, Mag. Christine Foussek, Dr. Rosina Hetterle, Univ. Prof. Dr. Heinrich Mächler, Univ. Prof. Dr. Peter Stix

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