Preferences and experiences of chronically ill and disabled patients regarding shared decision-making: does the type of care to be decided upon matter?

OBJECTIVE: (1) To describe the importance chronically ill and disabled patients attach to involvement in decision-making when various care types are considered, and (2) to analyse the degree to which these patients are involved in shared decision-making (SDM) regarding these care types, and whether their involvement reflects the importance they attach to SDM. METHODS: The study sample consisted of 812 chronically ill and disabled patients who experienced a situation of decision-making during the last year. Data were collected by a self-report survey in 2006 and were analysed by multilevel linear regression analyses. RESULTS: Participants attached most importance to SDM when occupational healthcare issues were at stake, but perceived their actual involvement in these decisions as relatively low. Patients dealing with decision-making regarding medical care or home care experienced higher levels of involvement. The importance attached to SDM corresponds moderately with the actual role patients experience in the decision-making process. CONCLUSION: The type of care to decide upon impacts on the importance patients attach to SDM as well as on their actual involvement in decision-making. PRACTICE IMPLICATIONS: We suggest healthcare practitioners to pay attention to the preferred level of patient involvement each time a new care issue has to be decided upon.

The intention to switch health insurer and actual switching behaviour: are there differences between groups of people?

BACKGROUND: Several western countries have introduced managed competition in their health care system. In the Netherlands, a new health insurance law was introduced in January 2006 making it easier to switch health insurer each year. OBJECTIVE: The objective was to measure people's intention to switch health insurer and actual switching behaviour. We also examined whether some groups were less inclined to switch health insurer and/or had more difficulty to exert their intention to switch. DESIGN: In October 2006, members of three Dutch panels indicated whether they intended to switch health insurer during that year's open enrollment period. In the beginning of 2007, the same people were asked whether they indeed switched health insurer. RESULTS: Only 1% intended to switch health insurer. Women, older people, lower educated people, people who were insured for a longer period and people who reported a bad or moderate health were less inclined to switch health insurer. The amount of switching was higher among individuals who intended to switch (31%) than among individuals who did not know whether they would switch (7%) and individuals with no intention to switch (2%). Among those who intended to switch health insurer, women and people who reported a good health switched health insurer more often. The years of enrollment were also associated with actual switching behaviour. DISCUSSION AND CONCLUSIONS: We might have to temper the optimistic expectations on enhanced choice. Future research should determine why people do not switch health insurer when they intend to and which barriers they experience.

Communication about work between general practitioners and patients consulting for musculoskeletal disorders.

BACKGROUND: Work-related musculoskeletal disorders (MSDs) are common in general practice. The communication between a general practitioner (GP) and patient is a key element of adequate general practice. No study has investigated the characteristics of communication about work-related matters during consultation of the GP by working patients with MSDs. OBJECTIVES: The aim of this study was to describe the communication about work-related matters between the GP and his patients with paid work who are consulting for MSDs. METHOD: Descriptive analysis of 680 systematic observations of GP consultations of patients in paid work who were consulting for MSDs. RESULTS: Work was discussed in 227 of 680 consultations in general practice. In 69% of these consultations the patient started communication concerning work-related matters, with an average number of 38.5 (standard deviation 45.7) verbal utterances, equalling, on average, 15% of the total consultation time. In 36% of consultations the patient's working conditions were discussed and in 12% the GP advised on whether to stay at home or return to work. There was a statistically significant positive correlation between the extent to which GPs rated the patient's MSDs to be work related and the number of utterances the GP and patient made about work-related matters during the consultation. CONCLUSIONS: Work is not a standard topic of conversation during the GP consultation. GPs could more often start communication about patients' work. A challenge for future GP practice and education is to include discussion of patients' work to optimise patient-centred care.

Can dimensions of national culture predict cross-national differences in medical communication?

OBJECTIVE: This study investigated at a country level how cross-national differences in medical communication can be understood from the first four of Hofstede's cultural dimensions, i.e. power distance, uncertainty avoidance, individualism/collectivism and masculinity/femininity, together with national wealth. METHODS: A total of 307 general practitioners (GPs) and 5820 patients from Belgium, Estonia, Germany, Great Britain, the Netherlands, Poland, Romania, Spain, Sweden and Switzerland participated in the study. Medical communication was videotaped and assessed using Roter's interaction analysis system (RIAS). Additional context information of physicians (gender, job satisfaction, risk-taking and belief of psychological influence on diseases) and patients (gender, health condition, diagnosis and medical encounter expectations) was gathered by using questionnaires. RESULTS: Countries differ considerably form each other in terms of culture dimensions. The larger a nation's power distance, the less room there is for unexpected information exchange and the shorter the consultations are. Roles are clearly described and fixed. The higher the level of uncertainty avoidance, the less attention is given to rapport building, e.g. less eye contact. In 'masculine' countries there is less instrumental communication in the medical interaction, which was contrary to expectations. In wealthy countries, more attention is given to psychosocial communication. CONCLUSION: The four culture dimensions, together with countries' wealth, contribute importantly to the understanding of differences in European countries' styles of medical communication. Their predictive power reaches much further than explanations along the north/south or east/west division of Europe. PRACTICE IMPLICATIONS: The understanding of these cross-national differences is a precondition for the prevention of intercultural miscommunication. Improved understanding may occur at microlevel in the medical encounter, as well as on macrolevel in pursuing more effective cooperation and integration of European health care policies.

The Dutch health insurance reform: switching between insurers, a comparison between the general population and the chronically ill and disabled.

BACKGROUND: On 1 January 2006 a number of far-reaching changes in the Dutch health insurance system came into effect. In the new system of managed competition consumer mobility plays an important role. Consumers are free to change their insurer and insurance plan every year. The idea is that consumers who are not satisfied with the premium or quality of care provided will opt for a different insurer. This would force insurers to strive for good prices and quality of care. Internationally, the Dutch changes are under the attention of both policy makers and researchers. Questions answered in this article relate to switching behaviour, reasons for switching, and differences between population categories. METHODS: Postal questionnaires were sent to 1516 members of the Dutch Health Care Consumer Panel and to 3757 members of the National Panel of the Chronically ill and Disabled (NPCD) in April 2006. The questionnaire was returned by 1198 members of the Consumer Panel (response 79%) and by 3211 members of the NPCD (response 86%). Among other things, questions were asked about choices for a health insurer and insurance plan and the reasons for this choice. RESULTS: Young and healthy people switch insurer more often than elderly or people in bad health. The chronically ill and disabled do not switch less often than the general population when both populations are comparable on age, sex and education. For the general population, premium is more important than content, while the chronically ill and disabled value content of the insurance package as well. However, quality of care is not important for either group as a reason for switching. CONCLUSION: There is increased mobility in the new system for both the general population and the chronically ill and disabled. This however is not based on quality of care. If reasons for switching are unrelated to the quality of care, it is hard to believe that switching influences the quality of care. As yet there are no signs of barriers to switch insurer for the chronically ill and disabled. This however could change in the future and it is therefore important to monitor changes.

Has patients' involvement in the decision-making process changed over time?

OBJECTIVE: To get insight into the changes over time of patients' involvement in the decision-making process, and into the factors contributing to patients' involvement and general practitioners' (GPs) communication related to the Medical Treatment Act (MTA) issues: information about treatment, other available treatments and side-effects; informed decision making; asking consent for treatment. BACKGROUND: Societal developments have changed the doctor-patient relationship recently. Informed decision making has become a central topic. Patients' informed consent was legalized by the MTA (1995). DESIGN: Data of two cross-sectional studies, the First (1987) and Second (2001) Dutch National Survey of General Practice, were compared. SETTING AND PARTICIPANTS: General practice consultations; 16 GPs and 442 patients in 1987; 142 GPs and 2784 patients in 2001. METHODS: Consultations were videotaped and rated using Roter's Interaction Analysis System and observer questionnaires; pre- and post-consultation patient questionnaires; and GP questionnaires. Descriptive analyses and multivariate, multilevel analysis were applied. MAIN RESULTS: Most patients reported to have received the information they had considered as important prior to the consultation. There were discrepancies in involvement in treatment decisions and in giving information about other available treatments, side-effects and risks. GPs who were more affective and gave more information, more often involved their patients, especially younger patients, in decision making. In 2001, more informed decision making was observed and the GPs asked consent for a treatment more often, but they less often asked for the patients' understanding. CONCLUSION: Patients' involvement in decision making has increased over time, but not in every respect. However, this does not apply for all patients, especially the older ones. It should be questioned whether they are willing or capable to be involved and if so, how they could be encouraged.

Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients.

BACKGROUND: Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002. METHODS: A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques. RESULTS: No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier. CONCLUSION: The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.

Patient expectations from consultation with family physician.

AIM: To assess patient expectations from a consultation with a family physician and determine the level and area of patient involvement in the communication process. METHOD: We videotaped 403 consecutive patient-physician consultations in the offices of 27 Estonian family physicians. All videotaped patients completed a questionnaire about their expectations before and after the consultation. Patient assessment of expected and obtained psychosocial support and biomedical information during the consultation with physician were compared. Two investigators independently assessed patient involvement in the consultation process on the basis of videotaped consultations, using a 5-point scale. RESULTS: Receiving an explanation of biomedical information and discussing psychosocial aspects was assessed as important by 57.4-66.8% and 17.8-36.1% patients, respectively. The physicians did not meet patient expectations in the case of three biomedical aspects of consultation: cause of symptoms, severity of symptoms, and test results. Younger patients evaluated the importance of discussing psychological problems higher than older patients. The involvement of the patients was high in the problem defining process, in the physicians' overall responsiveness to the patients, and in their picking up of the patient's cues. The patients were involved less in the decision making process. CONCLUSION: Discussing biomedical issues was more important for the patients than discussing psychological issues. The patients wanted to hear more about the cause and seriousness of their symptoms and about test results. The family physicians provided more psychosocial care than the patients had expected. Considering high patient involvement in the consultation process and the overall responsiveness of the family physicians to the patients during the consultation, Estonian physicians provide patient-centered consultations.

The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda.

PURPOSE: Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices. METHODS: This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations. RESULTS: For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance). CONCLUSION: Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits.

Is the communicative behavior of GPs during the consultation related to the diagnosis? A cross-sectional study in six European countries.

This study explores the relation between the diagnosis made by the general practitioner (GP) and his or her communicative behavior within a consultation, by means of the analysis of 2095 videotaped consultations of 168 GPs from six countries participating in the Eurocommunication study. The doctors' diagnoses were coded into ICPC chapters and merged into seven clinically relevant diagnostic clusters. The communicative behavior was gauged by means of the Roter interaction analysis system (RIAS). We found the most important differences for consultations about psychosocial problems as compared to all other diagnostic categories. In these consultations, doctors show more affective behavior, are more concerned about having a good relationship with their patients, ask more questions and give less information than in other consultations. The percentages of utterances in the other diagnostic categories were pretty similar. The communicative behavior of doctors reflects a global pattern in every consultation. This pattern is the most stable for affective behavior (social talk, agreement, rapport building and facilitation). Within instrumental behavior (the other categories), the directions and the information the doctor gives are adapted to the problems presented.

Consultation in general practice: a standard operating procedure?

The objectives of this study were to describe the features of consultation within general practice with special attention to the differences between short, moderate and long consultations. An analysis of 2801 videotaped consultations of 183 General Practitioners from six countries participating in the Eurocommunication Study was made. The communicative behaviour was gauged by means of the Roter Interaction Analysis System. The consultation can be seen as a "standard operating procedure" consisting of 8% social behaviour, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling. A short consultation can be described as an encounter with a little bit of social behaviour to set the contact, medical questioning, giving directions for the further consultation and advises in order to solve the problem(s) mentioned. In a long consultation doctors take more time for a social talk, they give more attention to the relation or contact with the patient, they listen more extensively, especially to psychosocial problems, and they give more information.

Demand and supply for psychological help in general practice in different European countries: access to primary mental health care in six European countries.

BACKGROUND: The general practitioner is usually the first health care contact for mental problems. The position of a general practitioner may vary between health care systems, depending on the referral system (gatekeepers versus directly accessible specialists), presence of fixed lists and the payment system. This may influence patients' expectations and requests for help and GPs' performance. In this paper the effects of working in different health care systems on demand and supply for psychological help were examined. METHODS: Data were collected in six European countries with different health care system characteristics (Belgium, Germany, The Netherlands, Spain, Switzerland and the UK). For 15 consecutive contacts with 190 GPs in the six countries, each patient completed questionnaires concerning reason for visit and expectations (before) and evaluation (after consultation). General practitioners completed registration forms on each consultation, indicating familiarity with the patient and diagnosis. General practitioners completed a general questionnaire about their personal and professional characteristics as well. RESULTS: Practices in different countries differed considerably in the proportion of psychological reasons for the visit by the patient and psychological diagnoses by the GP. Agreement between patients' self-rated problems and GPs' diagnoses also varied. Patients in different countries evaluated their GPs' psychological performance differently as well, but evaluation was not correlated with agreement between request for help and diagosis. In gatekeeping countries, patients had more psycho-social requests, GPs made more psychological diagnoses and agreement between both was relatively high. Evaluation, however, was more positive in non-gatekeeping countries. Individual characteristics of doctors and patients explained only a relatively small part of variance. CONCLUSIONS: Health care system characteristics do affect GPs' performance in psycho-social care.

Structure and duration of consultations in Estonian family practice.

OBJECTIVE: To study the influence of age, gender and the nature of the patient's problems on length of time of consultation in the practices of newly trained family doctors in a recently reconstructed health care system. DESIGN: Video-recordings of consultations with consecutive patients in family practice were studied for duration of consultation in relation to age, gender and nature of the problem(s). SETTING: Primary health care. SUBJECTS: 405 consecutive consultations were video-taped in the practices of 27 family doctors. MAIN OUTCOME MEASURES: Length of time of consultation and its segments was analysed using the Statistical Package for the Social Sciences. The problems were classified according to the ICPC. RESULTS: The average consultation lasted 9.0 min (+/- 4.9). Physical examination was 2.0 min (+/- 1.9) and was performed in 79% of all consultations. Respiratory and circulatory problems were the most common. More than one reason for the encounter was given in one-fourth of cases. Consultation time was longer for older age groups and for patients with psychological problems. CONCLUSION: Video-recording allows consultations to be evaluated directly and is acceptable to patients. The high participation rate of patients in our study can be explained by the individual approach and by the family doctor system. The period of consultation was dependent on patient age and on the number and nature of the problems, but was not influenced by gender.

Doctors' responses to patients' concerns: testing the use of sequential analysis.

AIMS: The aim of this small scale study was to explore interaction sequences during the medical consultation. Specific attention was paid to how doctors responded to patient's concerns and worries. Empathic behaviours (e.g. concern, partnership, legitimizing) and facilitating behaviours (e.g. paraphrasing, agreement) were considered as an adequate response to a patient's concern. METHODS: Nine consultations of nine different GPs were randomly selected from a sample of 1600 videotaped doctor-patient consultations, that were all rated with the Roter Interaction Analysis System. Each consultation contained at least 9 utterances of patient's concern. It was investigated how doctors respond within five lags of utterances after a patient's concern. RESULTS: The results showed that doctors more often responded to a patient's concern in a facilitative way than in an empathic way. When an empathic response was given, it appeared mostly during the first utterance after the patient expressed a concern. CONCLUSIONS: The findings indicate that sequential analysis is appropriate to investigate a health care provider's specific style of responding. Based on the problems emerged during the sequential analysis, further exploration of the method is recommended.

Communicating fatigue in general practice and the role of gender.

The aim of this study has been to obtain more insight into the health condition of fatigued patients, their expectations when visiting the general practitioner (GP), the way they communicate, and possible gender differences. Data consisted of 579 patient questionnaires and 440 video-observations of these patients and 31 GPs. Results showed that fatigue is a common health problem but seldom on the agenda in general practice. More women indicated symptoms of fatigue than men did. Fatigued patients' health was worse than that of non-fatigued patients, and they expected more biomedical and especially psychosocial communication. Furthermore, male fatigued patients expected more biomedical communication than fatigued female patients did. While the GPs accommodated their verbal behavior to fatigued patients by giving more psychosocial information and more counseling, they were not more affective towards the fatigued than towards the non-fatigued patients. Female GPs were more affective than their male colleagues, and they used gender-specific communication strategies to explore the patient's agenda. It seems necessary to use a gender-sensitive approach in communication research.

Consultation length in general practice: cross sectional study in six European countries.

OBJECTIVES: To compare determinants of consultation length discussed in the literature with those found in consultations with general practitioners from different European countries; to explore the determinants of consultation length, particularly the effect of doctors' and patients' perceptions of psychosocial aspects. DESIGN: Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients. SETTING: General practices in six European countries. PARTICIPANTS: 190 general practitioners and 3674 patients. RESULTS: In a multilevel analysis with three levels (country, general practitioner, and patient), country and doctor variables contributed a similar amount to the total variance in consultation length (23% and 22%, respectively) and patient variables accounted for 55% of the variance. The variables used in the multilevel analysis explained 25% of the total variation. The country in which the doctor practised, combined with the doctors' variables, was as important for the variance in consultation length as the variation between patients. Consultations in which psychosocial problems were considered important by the doctor and the patient lasted longer than consultations about biomedical problems only. The doctor's perception had more influence in this situation than the patient's. Consultation length is influenced by the patients' sex (women got longer consultations), whether the practice was urban or rural, the number of new problems discussed in the consultation (the more problems the longer the consultation), and the patient's age (the older the patient the longer the consultation). As a doctor's workload increased, the length of consultations decreased. The general practitioner's sex or age and patient's level of education were not related to the length of consultation. CONCLUSION: Consultation length is determined by variables related to the doctor and the doctor's country as well as by those related to patients. Women consulting in an urban practice with problems perceived as psychosocial have longer consultations than other patients.