Review
Patient participation in the consultation process: A structured review of intervention strategies

https://doi.org/10.1016/j.pec.2005.10.005Get rights and content

Abstract

Objective

To describe the range and effectiveness of intervention strategies designed to enhance patient participation in the consultation process.

Methods

A systematic review of published literature (1976–2004) was undertaken. Controlled trials in English were included. Data regarding study design, intervention characteristics, patient populations and study results were extracted.

Results

One hundred and forty-six articles describing 137 trials were reviewed. A pragmatic categorisation of intervention strategies and study outcomes supported data synthesis. Patient-targeted coaching and educational materials, and provider-targeted communication skills training have a substantial impact on communication. Information feedback to providers from patient-reported outcome measures (PROMs) benefits provider diagnosis and management of patient conditions. Communication and provider diagnosis and management benefit most from the reviewed interventions. Although patient satisfaction and health status were two of the most frequently measured outcomes, overall, the interventions appeared to have less impact on patient self-efficacy, attitudes and behaviours, patient satisfaction, health status and resource use.

Conclusion

Evidence is insufficient to strongly advocate one approach to enhancing patient participation in the consultation process. More rigorous research design with clearly specified intervention strategies and appropriately defined outcomes assessed over both the short and long term is required.

Practice implications

Although limited and inconclusive, the most extensive and most encouraging evidence to enhance patient participation in the consultation process is available for three patient-targeted intervention strategies (coaching, educational materials and PROMs feedback to providers) and one provider-targeted intervention strategy (communication skills training).

Introduction

Patient and public participation in decisions about health and healthcare is a central goal of healthcare systems. Enabling patients to effectively communicate personal values, priorities and expectations for health to healthcare providers, to participate in shared decision-making and to evaluate the relative success of healthcare are important elements of patient participation and patient-centred care [1], [2], [3]. Such participation should lead to a more comprehensive appreciation of the health problem, and management solutions and outcomes that are agreed between patient and healthcare provider [2], [4], greater patient adherence, satisfaction with treatment and improved health status may ensue. However, facilitating patient participation throughout the various stages of the healthcare process has wide ranging implications and requires a major shift in the way in which healthcare is delivered. Moreover, uncertainty may exist with regards to the importance of patient participation and rigorous evidence is lacking relating to the mechanisms by which this may be best achieved.

The clinical consultation provides an important opportunity for patients to participate in the healthcare process and to engage with a range of healthcare providers. Increasing the effectiveness of these interactions is essential to patient-centred care. A wide range of methods has been described to facilitate this process, including the provision of checklists for patients [5] and educational programmes for providers [6]. However, there is varying evidence for the relative success of these interventions and clear guidance on the most appropriate methods for enhancing patient participation, and hence improving the quality of patient-centred care, is lacking. Although several published reviews of the effectiveness of interventions are available these are few and have generally limited their coverage to one specific type of intervention, have specified a priori theoretical frameworks, or limited outcomes to be assessed in interventions reviewed [7], [8], [9], [10], [11]. Due to the pressure on healthcare providers to embrace patient-centred care and the expanding nature of the field, it is timely to provide a more inclusive review of the diversity of methods to enhance patient participation in the clinical consultation.

The aim of the study was to describe and review specific practical mechanisms targeted at patients and/or providers and designed to enhance patient participation in the consultation process, and to examine the impact of these mechanisms on the outcomes of care. As with earlier reviews [10], [11], [12] the current review was confined to well-designed studies.

Section snippets

Methods

The starting point for the review was to identify the wide range of patient- and/or provider-targeted mechanisms that were designed to enhance the patients’ ability to participate in the consultation process with a healthcare provider. The common feature was broadly to focus on mechanisms of patient participation and not particular theoretical concepts, philosophies or rationales underpinning patient participation, partnership or involvement.

Patient participation was operationalised as an

Search results

A total of 7532 titles were returned by the electronic search strategies: 3090 main search and 4442 secondary searches. One thousand two hundred and sixteen abstracts were reviewed, of which 193 articles were potentially relevant and reviewed in full. A total of 105 articles met inclusion criteria and were included in the review. Searching the reference lists of included articles and structured reviews of included intervention strategies identified a further 34 articles; 5 additional articles

Discussion

The facilitation of patient participation in the healthcare process is a key element of patient-centred care. This study provides a timely contribution to the field of patient-centred care by describing a wide ranging review and pragmatic classification of intervention strategies, mostly targeted toward the patient, for increasing patient participation in healthcare particularly in the consultation process. Despite being complicated by the wide range of reviewed intervention strategies and the

Acknowledgements

This work was undertaken by Kirstie Haywood, Susan Marshall and Ray Fitzpatrick, on behalf of the Patient-reported Health Instruments Group, National Centre for Health Outcomes Development, University of Oxford. The manuscript is informed by a report to the UK Department of Health (Patient Involvement and Collaboration in Shared Decision-Making: a structured review to inform chronic disease management. The report is downloadable free of charge: http://phi.uhce.ox.ac.uk). The views expressed in

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