Assessing patient-centered communication in a family practice setting: how do we measure it, and whose opinion matters?

OBJECTIVE: This study evaluated variables thought to influence patient's perceptions of patient-centeredness. We also compared results from two coding schemes that purport to evaluate patient-centeredness, the Measure of Patient-Centered Communication (MPCC) and the 4 Habits Coding Scheme (4HCS). METHODS: 174 videotaped family practice office visits, and patient self-report measures were analyzed. RESULTS: Patient factors contributing to positive perceptions of patient-centeredness were successful negotiation of decision-making roles and lower post-visit uncertainty. MPCC coding found visits were on average 59% patient-centered (range 12-85%). 4HCS coding showed an average of 83 points (maximum possible 115). However, patients felt their visits were highly patient-centered (mean 3.7, range 1.9-4; maximum possible 4). There was a weak correlation between coding schemes, but no association between coding results and patient variables (number of pre-visit concerns, attainment of desired decision-making role, post-visit uncertainty, patients' perception of patient-centeredness). CONCLUSIONS: Coder inter-rater reliability was lower than expected; convergent and divergent validity were not supported. The 4HCS and MPCC operationalize patient-centeredness differently, illustrating a lack of conceptual clarity. PRACTICE IMPLICATIONS: The patient's perspective is important. Family practice providers can facilitate a more positive patient perception of patient-centeredness by addressing patient concerns to help reduce patient uncertainty, and by negotiating decision-making roles.

Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects.

Relapse and recurrence following response to acute-phase treatment for major depressive disorder (MDD) are prevalent and costly. In a meta-analysis of 28 studies including 1,880 adults, the authors reviewed the world's published literature on cognitive-behavioral therapies (CT) aimed at preventing relapse-recurrence in MDD. Results indicate that after discontinuation of acute-phase treatment, many responders to CT relapse-recur (29% within 1 year and 54% within 2 years). These rates appear comparable to those associated with other depression-specific psychotherapies but lower than those associated with pharmacotherapy. Among acute-phase treatment responders, continuation-phase CT reduced relapse-recurrence compared with assessment only at the end of continuation treatment (21% reduction) and at follow-up (29% reduction). Continuation-phase CT also reduced relapse-recurrence compared with other active continuation treatments at the end of continuation treatment (12% reduction) and at follow-up (14% reduction). The authors discuss implications for research and patient care and suggest directions, with methodological refinements, for future studies.

Selection of outcome assessment instruments for inpatients with severe and persistent mental illness.

The purpose of this article is to describe a procedure to assist in selecting outcome measures for inpatients treated at a state psychiatric hospital. The procedure combines evidence-based criteria from the literature, instruments shown to be sensitive to change in clinical trials, and the perspectives of a multidisciplinary team of researchers, administrators, providers, and patient advocates. Recent efficacy and effectiveness studies were used to identify recurrently used outcome instruments. A computerized search of more than 30 bibliographic databases, such as PsycINFO, MEDLINE, Social SciSearch, and ERIC, was conducted for articles published between 1990 and 2002. Comparisons of the most frequently used instruments were made on seven criteria proposed as best-practice indicators, including sensitivity to change and robust psychometrics. The sample produced 110 measures. Rater-completed instruments were represented more often than patient-completed ones. However, considerable variability across both methods was found on the criteria. The limited resources associated with publicly funded inpatient facilities led to a recommendation to select at least one rater-completed and one patient-completed instrument.