2012 National Healthcare Quality Report

Chapter 5. Patient Centeredness

The Institute of Medicine identifies patient centeredness as a core component of quality health care (IOM, 2001a). Patient centeredness is defined as:

[H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care (IOM, 2001b).

Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient" (IOM, 2001a). In addition, translation and interpretation services facilitate communication between the provider and the patient and are often a legal requirement.i The patient-centered approach includes viewing the patient as a unique person, rather than focusing strictly on the illness, building a therapeutic alliance based on the patient's and the provider's perspectives.

Patient-centered care is supported by good provider-patient communication so that patients' needs and wants are understood and addressed and patients understand and participate in their own care (IOM, 2001b). This approach to care has been shown to improve patients' health and health care (DiMatteo, 1998; Stewart, et al., 2000; Little, et al., 2001; Anderson, 2002; Beck, et al., 2002). Unfortunately, many barriers exist to good communication.

Providers also differ in communication proficiency, including varied listening skills and different views from their patients of symptoms and treatment effectiveness (Rhoades, et al., 2001). Additional factors influencing patient centeredness and provider-patient communication include:

  • Language barriers.
  • Racial and ethnic concordance between the patient and provider.
  • Effects of disabilities on patients' health care experiences.
  • Providers' cultural competency.

Efforts to remove these possible impediments to patient centeredness are underway within the Department of Health and Human Services (HHS). For example, the Office of Minority Health has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help promote patient-centered care (HHS, 2011).ii These modules are based on the National Standards on Culturally and Linguistically Appropriate Services. The standards are directed at health care organizations and aim to improve patient centeredness of care for people with limited English proficiency (LEP). Another example, which is administered by the Health Resources and Services Administration, is Effective Communication Tools for Healthcare Professionals, a Web-based course for providers that integrates concepts related to health literacy with cultural competency and LEP.iii

Similarly, the HHS Office for Civil Rights (OCR), in partnership with 18 medical schools in the National Consortium for Multicultural Education, funded by the National Institutes of Health, provides a course on cultural competency in medicine. The course, Stopping Discrimination Before It Starts: The Impact of Civil Rights Laws on Health Care Disparities,iv focuses on Title VI compliance. This course discusses, in part, the HHS OCR's Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. This guidance explains that recipients of Federal financial assistance must take reasonable steps to give individuals with LEP a meaningful opportunity to participate in HHS-funded programs. Failure to do so may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq., against national origin discrimination (HHS, 2003).

In addition, the HHS OCR is responsible for the enforcement of Section 1557 of the Affordable Care Act, 42 U.S.C. 18116. This section provides that an individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. (race, color, national origin); Title IX of the Education Amendments of 1972, 20 U.S.C. 1681 et seq. (sex); the Age Discrimination Act of 1975, 42 U.S.C. 6101 et seq. (age); or Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794 (disability), under any health program or activity, any part of which is receiving Federal financial assistance, or under any program or activity that is administered by an executive agency or any entity established under Title I of the Affordable Care Act or its amendments.

On February, 26, 2013, the Department published its 2013 Language Access Plan (2013 HHS LAP; HHS, 2013), ensuring access to HHS programs and activities for people with LEP. The covered programs and activities include, but are not limited to, Medicare, Medicaid, and the Children's Health Insurance Program. The 2013 HHS LAP was developed by the HHS Language Access Steering Committee, which is led by the Director of the OCR on behalf of the Secretary.

In accordance with Executive Order 13166, Improving Access to Services for Persons With Limited English Proficiency (White House, 2000), the 2013 HHS LAP establishes the Department's policy and strategy for serving individuals with LEP and reaffirms the Department's commitment to language access principles. The 2013 HHS LAP serves as a blueprint for HHS staff and operating divisions charged with developing their own agency-specific language access plans. Additional information regarding language access requirements is available from the Department of Justice (DOJ, 2011).

The 2013 HHS LAP is organized into 10 cross-cutting elements:

  1. Assessment—Needs and Capacity;
  2. Oral Language Assistance Services;
  3. Written Translations;
  4. Policies and Procedures;
  5. Notification of the Availability of Language Assistance at No Cost;
  6. Staff Training;
  7. Assessment—Access and Quality;
  8. Stakeholder Consultation;
  9. Digital Information; and
  10. Grant Assurance and Compliance.

Importance

Morbidity and Mortality

  • Patient-centered approaches to care have been shown to improve patients' health status. These approaches rely on building a provider-patient relationship, improving communication, fostering a positive atmosphere, and encouraging patients to actively participate in provider-patient interactions (Stewart, et al., 2000; Anderson, 2002).
  • A patient-centered approach has been shown to lessen patients' symptom burden (Little, et al., 2001).
  • Patient-centered care encourages patients to comply with treatment regimens (Beck, et al., 2002).
  • Patient-centered care can reduce the chance of misdiagnosis due to poor communication (DiMatteo, 1998).

Cost

  • Patient centeredness has been shown to reduce underuse and overuse of medical care (Berry, et al., 2003).
  • Patient centeredness can reduce the strain on system resources and save money by reducing the number of diagnostic tests and referrals (Little, et al., 2001).
  • Although some studies have shown that being patient centered reduces medical costs and use of health service resources, others have shown that patient centeredness increases providers' costs, especially in the short run (Bechel, et al., 2000).

Measures

The National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) track several measures of patients' experience of care. The reports also address the priority of ensuring that each person and family is engaged as partners in their care, found in the National Strategy for Quality Improvement in Health Care (National Quality Strategy).v The rationale is that "[h]ealth care should give each individual patient and family an active role in their care. Care should adapt readily to individual and family circumstances, as well as differing cultures, languages, disabilities, health literacy levels, and social backgrounds." Examples of person-centered care could be ensuring that patients' feedback on their preferences, desired outcomes, and experiences of care is integrated into care delivery and enabling patients to effectively manage their care.

The NHQR has tracked a growing number of patient centeredness measures. Organized around the National Quality Strategy, the 2012 NHQR presents the following measures that relate to the goal to provide patient-centered care:

  • Adults and children who reported poor communication at the doctor's office (composite).
  • Adults who reported poor communication with nurses and doctors at the hospital.
  • Provider's involvement of the patient in making treatment decisions.

The last measure also relates to the National Quality Strategy goal of patient engagement.

Findings

Patients' Experience of Care—Adults

Optimal health care requires good communication between patients and providers, yet barriers to provider-patient communication are common. To provide all patients with the best possible care, providers need to understand patients' diverse health care needs and preferences and communicate clearly with patients about their care.

 Figure 5.1. Composite: Adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers, by insurance, ages 18-64 and age 65 and over, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population age 18 and over who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • From 2002 to 2009, there were no statistically significant changes in the percentage of adults with any private insurance, public insurance, or no insurance who had a doctor's office or clinic visit and reported poor communication (Figure 5.1).
  • From 2002 to 2009, a significantly lower percentage of adults with private insurance reported poor communication with their health providers compared with adults who were uninsured and those with public insurance (in 2009, 8.3% compared with 17.6% and 13.7%, respectively).
  • In 2009, the percentage of people reporting poor communication with their health providers was significantly higher for those with Medicare and other public insurance than for those with Medicare only or Medicare and private insurance (9.6% compared with 6.2% and 4.7%, respectively).

Also, in the NHDR:

  • From 2002 to 2009, poor and low-income adults were more likely than high-income adults to report poor communication with health providers.

Patients' Experience of Care—Children

Communication in children's health care can be challenging since the child's experiences are interpreted through the eyes of a parent or guardian. During a health care encounter, a responsible adult caregiver will be involved in communicating with the provider and interpreting decisions to the patient in an age-appropriate manner. Optimal communication in children's health care can therefore have a significant impact on receipt of high-quality care and subsequent health status.

  Figure 5.2. Composite: Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers, by insurance and primary language, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population under age 18 who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • From 2002 to 2009, the percentage of children whose parents reported poor communication significantly decreased for all insurance groups (Figure 5.2). During the same period, the percentage significantly decreased for both primary language groups as well.
  • In 2009, the percentage of children whose parents reported poor communication was higher for those with public insurance only than for those with any private insurance.
  • In 2009, the percentage of children whose parents reported poor communication with health providers was higher for those whose preferred language was something other than English compared with those whose preferred language was English.

Also, in the NHDR:

  • From 2002 to 2009, the percentage of children whose parents or guardians reported poor communication significantly decreased among Hispanics.

  Figure 5.3. State variation: Children whose parents reported poor communication with health providers

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2009.
Denominator: Civilian noninstitutionalized population under age 18 who had a doctor's office or clinic visit in the last 12 months.
Note: Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • Although data were not available for all States (only available for 28 States), there was significant variation across the Nation in the percentage of children whose parents reported poor communication with health providers (Figure 5.3).
  • The ranges for the quartiles are:
    • First (best) quartile: 4.6%-7.2%.
    • Second quartile: 7.3%-8.19%.
    • Third quartile: 8.2%-8.9%.
    • Fourth (worst) quartile: 9%-16%.

Patients' Experience of Care—Hospital

Using methods developed for the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey (Hargraves, et al., 2003), the NHQR and NHDR use a composite measure that combines three measures of provider-patient communication into a single core measure. The composite measure presented includes data on providers who sometimes or never listened carefully, explained things clearly, and respected what patients had to say. These data are presented separately for communication with nurses and communication with doctors.

  Figure 5.4. Adult hospital patients who reported poor communication with nurses and doctors, by age, 2008-2010

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Source: Agency for Healthcare Research and Quality, Hospital CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey, 2008-2010.
Denominator: Adult hospitalized patients.
Note: For this measure, lower rates are better. Poor communication is defined as responded sometimes or never to the set of survey questions: "During this hospital stay, how often did doctors/nurses treat you with courtesy and respect?" "During this hospital stay, how often did doctors/nurses listen carefully to you?" and "During this hospital stay, how often did doctors/nurses explain things in a way you could understand?"

  • In 2010, 5.3% of adult hospital patients reported poor communication with doctors during their hospital stay, and 5.2% reported poor communication with nurses (data not shown).
  • In 2010, patients age 65 and over were less likely to report poor communication with nurses compared with patients ages 18-44 (4.9% compared with 5.6%).
  • In the same year, patients ages 45-64 were more likely to report poor communication with doctors compared with patients ages 18-44 (5.7% compared with 4.9%).

Also, in the NHDR:

  • In 2010, all minority groups were more likely than Whites to report poor communication with nurses.
  • Blacks, American Indians and Alaska Natives, and patients of more than one race were more likely than Whites to report poor communication with doctors.

Patient and Family Engagement: Enabling Effective Patient Navigation and Management of Care

To effectively navigate the complicated health care system, health care providers need to give patients access to culturally and linguistically appropriate tools to support patient engagement. Culturally and linguistically appropriate services (CLAS) are important components of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.

Health literacy is the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions (HHS, 2000). Patients with limited health literacy are more likely to have difficulty understanding instructions and taking medication properly. In addition, communication barriers such as limited English proficiency are associated with lower quality of care and place patients at risk for poor clinical outcomes (Ngo-Metzger, et al., 2007).

About one-third of Americans are not "health literate" (Gazmararian, et al. 2003; Parker, et al., 2003). Individuals with inadequate health literacy incur higher medical costs and are more likely to have an inefficient mix of service use compared with those with adequate health literacy (Howard, et al., 2005). They may experience many difficulties, including:

Providers Asking Patients To Assist in Making Treatment Decisions

The increasing prevalence of chronic diseases has placed more responsibility on patients, since conditions such as diabetes and hypertension require self-management. Patients need to be provided with information that allows them to make educated decisions and feel engaged in their treatment. Treatment plans also need to incorporate their values and preferences.

  Figure 5.5. Adults with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions, by education, 2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2009.
Denominator: Civilian noninstitutionalized population with a usual source of care.
Note: For this measure, lower rates are better.

  • In 2009, patients with a high school education and less than a high school education were significantly more likely than patients with any college education to have a usual source of care who did not ask for their help in making treatment decisions (16.8% and 19.8%, respectively, compared with 14.2%; Figure 5.5).
  • From 2002 to 2009, the percentage of patients whose usual source of care did not ask for their help in making treatment decisions decreased for the total population and all education groups (total population from 21.9% to 15.4%; data not shown).

Also, in the NHDR:

  • In 2009, Black and Hispanic patients were significantly more likely than White patients to have a usual source of care who did not ask for their help in making treatment decisions.

References

Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues 2002;16(12):80-82.

Baker DW, Gazmararian, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. am J Public Health 2002;92(8):1278-83.

Baker DW, Parker RM, Williams MV, et al. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13(12):791-8.

Bechel DL, Myers WA, Smith DG. Does patient-centered care pay off? Jt Comm J Qual Improv 2000;26(7):400-9.

Beck, RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002;15(1):25-38.

Berkman, N, DeWalt D, Pignone M. Literacy and health outcomes. Summary. Evidence Report/Technology Assessment No. 87. Rockville, MD: Agency for Healthcare Research and Quality; 2004. AHRQ Publication No. 04-E007-1.

Berry LL, Seiders K, Wilders SS. Innovations in access to care: a patient-centered approach. Ann Intern Med 2003;139(7):568-74.

DiMatteo MR The role of the physician in the emerging health care environment. West J Med 1998;168(5):328-33.

Gazmararian JA, Williams MV, Peel J, et al. Health literacy and knowledge of chronic disease. Patient Educ Couns 2003;51(3):267-75.

Hargraves JL, Hays RD, Cleary PD, et al. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey. Health Serv Res 2003;38(6 Pt 1):1509-27.

Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med 2005;118(4):371-7.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001a.

Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press; 2001b.

Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ 2001;323(7318):908-11.

Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med 2007;22 Suppl 2:324-30.

Parker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing high-quality health care. Health Aff (Millwood) 2003;22(4):147-53.

Rhoades DR, McFarland KF, Finch WH. Speaking and interruptions during primary care office visits. Fam Med 2001;33(7):528-32.

Scott TL, Gazmararian JA, Williams MV, et al. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40(5):395-404.

Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49(9):796-804.

U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. Washington, DC: Government Printing Office; 2000.

U.S. Department of Health and Human Services. Language Access Plan 2013. Available at: http://www.hhs.gov/open/execorders/13166/. Accessed February 27, 2013.

U.S. Department of Health and Human Services, Office for Civil Rights. Guidance to federal financial assistance recipients regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. 68 Fed Reg 47311-47323; August 8, 2003. Available at: http://www.gpo.gov/fdsys/pkg/FR-2003-08-08/pdf/03-20179.pdf [Plugin Software Help]. Accessed February 22, 2013.

U.S. Department of Health and Human Services, Office of Minority Health. Think cultural health: bridging the health care gap through cultural competency continuing education programs. Available at: http://www.thinkculturalhealth.hhs.gov. Accessed August 11, 2011.

U.S. Department of Justice, Civil Rights Division, Federal Coordination and Compliance Section. Common language access questions, technical assistance, and guidance for federally conducted and federally assisted programs. Washington, DC; August 2011. Available at: http://www.lep.gov/resources/081511_Language_Access_CAQ_TA_Guidance.pdf [Plugin Software Help]. Accessed February 22, 2013.

White House. Executive Order 13166: Improving access to services for persons with limited English proficiency. 65 Fed Reg 50121; August 16, 2000. Available at: http://www.gpo.gov/fdsys/pkg/FR-2000-08-16/pdf/00-20938.pdf [Plugin Software Help]. Accessed February 27, 2013.

Williams MV, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114(4):1008-15.

Williams MV, Baker DW, Parker RM, et al. Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998 Jan 26;158(2):166-72.


i. For example, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, may require the practitioner or hospital to provide language interpreters and translate vital documents for limited-English-proficient persons. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, may require the practitioner or hospital to provide sign language interpreters, materials in Braille, and/or accessible electronic formats for individuals with disabilities.
ii. This free, online educational program (available at www.thinkculturalhealth.hhs.gov) is accredited for Continuing Medical Education credits for physicians, as well as Continuing Education Units for physician assistants, nurse practitioners, registered nurses, social workers, and emergency response personnel.
iii. This online program (available at www.hrsa.gov/publichealth/healthliteracy/) is accredited for Continuing Medical Education credits for physicians and Continuing Education Units for nurses, physician assistants, pharmacists, and Certified Health Education Specialists.
iv. This course (available in the Association of American Medical Colleges' MedEdPORTAL, https://www.mededportal.org/publication/7740 ) has been presented at five national medical schools. Emory University School of Medicine and the University of Colorado School of Medicine have incorporated this course into their fourth year curriculums.
v. Available at http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Quality Report: Chapter 5. Patient Centeredness. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr12/chap5.html