17
Measuring Patient Perceptions of Patient-Centeredness
Moira Stewart, Leslie Meredith, Bridget L Ryan, and Judith Belle Brown
Introduction
Measures of patients’ perception of patient-centered care have been developed that serve to supplement and complement the behavioral measure (MPCC) described in the next chapter. What more patient-centered research approach could one imagine than asking the patient to describe his or her experience of the visit with the clinician in a formal structured way? The measures, described in this chapter, have been used for research, but as well for education, by providing individual feedback to participating physicians on their patients’ perceptions.
Patient perception measures are increasingly used to evaluate health care because of the seminal paper of Rosenthal and Shannon (1997). Standard questionnaires to assess patients’ views of themselves or to assess their satisfaction with care (which includes implicit comparisons by patients between their perceptions of care and their expectations of care) are not the topic of this chapter. Rather, this chapter covers patients’ reports of a recent experience of care. Other researchers have chosen such a focus to evaluate primary care generally (Starfield, 1998; Haddad, 2000; Greco et al. , 2001; Steine et al. , 2001; Takemura et al. , 2006; Campbell et al. , 2007; Makoul et al. , 2007). In general, such measures are more sensitive to health care delivery changes than long-term health outcome measures, less expensive and more reliable than clinician review methods, and focused on positive aspects of care (not mistakes), hence very suitable for quality improvement initiatives (Rosenthal & Shannon, 1997). These qualities make patient perception measures an important component of any health care research program.
Other researchers who have applied the patient perception approach to the study of patient-centered care include Little et al. (2001b). They developed a 21-item questionnaire that they found to be reliable (Cronbach’s alpha ranging from 0.96 to 0.84) and which factored into five factors very similar to the components of the patient-centered clinical method described in this book (see Chapter 1 ). Little et al. ’s (2001b) questionnaire was used before a visit to assess patient preferences (patients overwhelmingly preferred all facets of a patient-centered approach) and after the visit to assess patient perceptions of their experience.
The current chapter presents the questionnaire measures of patients’ perception of the patient-centered clinical method described in this book (see Chapters 3–7).
The Measure of Patient Perception of Patient-Centeredness
Measure Development
The 17 items developed by our colleagues Carol Buck and Martin Bass for a study of patient outcomes in family practice (Bass et al. , 1986), were adapted for a study of communication in family practice (Henbest & Stewart, 1990). The latter study served as a partial validation, in that the items on patients’ perceptions of the physicians’ ascertainment of the presenting problems were correlated with a patient-centered score of the audiotaped encounter (Spearman rank correlating coefficients ranging from 0.296 to 0.416; p values ranging from 0.006 to 0.001; n = 73; Henbest & Stewart, 1990). Revision of the 1990 version (eliminating four items for poor response or irrelevance to the concepts and adding one relevant item) led to the current 14-item version of the Patient Perception of Patient-Centeredness (PPPC) questionnaire (see Table 17.1), which was used in two large studies: one of 39 randomly selected family physicians and 315 patients (Stewart et al. , 2000); and a version adapted for cancer care in a second study of 52 family physicians, oncologists, and surgeons (Stewart et al. , 2007b).
In the late 1990s, pressure to create a shorter version for easy use in practice, especially for the purpose of continuous quality improvement, led to the selection of eight items that were found to significantly associate with either the objective measure of patient-centeredness (presented in the next chapter, Chapter 18 ) or a health outcome in the 2000 study, plus one new item thought to be necessary to reflect all the components of the patient-centered clinical method. This nine-item questionnaire has two versions: one for the patient to complete and one for the clinician to complete.
Researchers from across Canada and around the world have requested the working paper that describes these two versions of the PPPC (Stewart et al. , 2004). Since publication of the second edition of this book in 2003, over 100 requests have been received from Argentina, Australia, Brazil, Columbia, Germany, Italy, Japan, Korea, the Netherlands, Norway, Russia, Sarajevo, Spain, Switzerland, Taiwan, Turkey, the United Arab Emirates, the United Kingdom, and the United States.
The 14-item PPPC has been used in studies with the general population (Stewart et al. , 2000; Reinders et al. , 2009) and with specialized populations such as breast cancer survivors (Stewart et al. , 2007b; Clayton & Dudley, 2008, 2009), and the elderly (Ishikawa et al. , 2005). As well as having been used with real patients, the PPPC has also been used with standardized patients (Fiscella et al. , 2007).
Reliability and Validity of the Patient Perception of Patient-Centeredness
Inter-item reliability has been found to be adequate for the 14-item PPPC (Cronbach’s alpha = 0.71, n = 315). The internal reliabilities (Cronbach’s alpha) for the 14-item PPPC total score in four additional international studies are 0.91 (adapted to 12 items, n = 145, Ishikawa et al. , 2005); 0.90 (n = 2907, Fiscella et al. , 2007); 0.82 (n = 60, Clayton and Dudley, 2008, 2009); and 0.83 (n = 222, Reinders et al. , 2009).
The validity of the 14-item PPPC was established through (1) a significant correlation with the objective measure (see Chapter 18 ) (r = 0.16; p = 0.01; n = 315) and (2) significant correlations with patient health outcomes and with efficiencies in the use of health services (Stewart et al. , 2000).
Cronbach’s alpha reliability of the nine-item patient questionnaire is 0.80 (n = 85). Similarly, Cronbach’s alpha of the nine-item physician questionnaire is 0.79 (n = 117). Validity is based on the origin of the items. Eight items were significantly related to either the objective measure (see Chapter 18 ) or a patient health outcome measure. The remaining item was added to enhance content validity.
The Items
The 14-item PPPC is shown in Table 17.1. There are four items thought by the researchers to be relevant to Component 1: Exploring the Illness Experience; one item for Component 2: Understanding the Whole Person; and nine items for Component 3: Finding Common Ground.
TABLE 17.1 The 14-item Patient Perception of Patient-Centeredness
| Patient Perception of Patient-Centeredness | |||||
|---|---|---|---|---|---|
| Please CIRCLE the response that best represents your opinion . | |||||
| 1. | To what extent was your main problem(s) discussed today? | Completely | Mostly | A little | Not at all |
| 2. | Would you say that your provider knows that this was one of your reasons for coming in today? | Yes | Probably | Unsure | No |
| 3. | To what extent did the provider understand the importance of your reason for coming in today? | Completely | Mostly | A little | Not at all |
| 4. | How well do you think your provider understood you today? | Very well | Well | Somewhat | Not at all |
| 5. | How satisfied were you with the discussion of your problem? | Very satisfied | Satisfied | Somewhat satisfied | Not satisfied |
| 6. | To what extent did the provider explain this problem to you? | Completely | Mostly | A little | Not at all |
| 7. | To what extent did you agree with the provider’s opinion about the problem? | Completely | Mostly | A little | Not at all |
| 8. | How much opportunity did you have to ask your questions? | Very much | A fair amount | A little | Not at all |
| 9. | To what extent did the provider ask about your goals for treatment? | Completely | Mostly | A little | Not at all |
| 10. | To what extent did the provider explain treatment? | Very well | Well | Somewhat | Not at all |
| 11. | To what extent did the provider explore how manageable this (treatment) would be for you? He/she explored this: | Completely | Mostly | A little | Not at all |
| 12. | To what extent did you and the provider discuss your respective roles? (Who is responsible for making decisions and who is responsible for what aspects of your care?) | Completely | Mostly | A little | Not at all |
| 13. | To what extent did the provider encourage you to take the role you wanted in your own care? | Completely | Mostly | A little | Not at all |
| 14. | How much would you say that this provider cares about you as a person? | Very much | A fair amount | A little | Not at all |
Three scores can be created from PPPC. The 14-item measure was coded so that low scores meant positive perceptions in keeping with other patient outcomes where fewer problems or low scores means a better outcome. The total score is the sum of all responses divided by 14. The second score is for Component 1, in which responses to items 1, 2, 3, and 4 are summed and divided by 4. (The reader will notice that there is only one item for Component 2, item 14, so there is no computed score.) The third score is for Component 3 in which responses to items 5–13 are summed and divided by 9.
TABLE 17.2 Self-Assessment and Feedback on Communication With Patients: Patient Assessment
| Please check (✓) the box that best represents your response. | |||||
|---|---|---|---|---|---|
| 1. | To what extent was your main problem(s) discussed today? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 2. | How satisfied were you with the discussion of your problem? | Very satisfied ☐ | Satisfied ☐ | Somewhat satisfied ☐ | Not satisfied ☐ |
| 3. | To what extent did the provider listen to what you had to say? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 4. | To what extent did the provider explain this problem to you? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 5. | To what extent did you and the provider discuss your respective roles? (Who is responsible for making decisions and who is responsible for what aspects of your care?) | Completely ☐ | Mostly ☐ | A little ☐ | Not discussed ☐ |
| 6. | To what extent did the provider explain treatment? | Very well ☐ | Well ☐ | Somewhat ☐ | Not at all ☐ |
| 7. | To what extent did the provider explore how manageable this (treatment) would be for you? He/she explored this … | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 8. | How well do you think your provider understood you today? | Very well ☐ | Well ☐ | Somewhat ☐ | Not at all ☐ |
| 9. | To what extent did the provider discuss personal or family issues that might affect your health? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
TABLE 17.3 Self-Assessment and Feedback on Communication With Patients: Clinician Assessment
| Please check ( ✓ ) the box that best represents your response. | |||||
|---|---|---|---|---|---|
| 1. | To what extent was your patient’s main problem(s) discussed today? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 2. | How satisfied were you with the discussion of your patient’s problem? | Very satisfied ☐ | Satisfied ☐ | Somewhat satisfied ☐ | Not satisfied ☐ |
| 3. | To what extent did you listen to what your patient had to say? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 4. | To what extent did you explain the problem to the patient? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 5. | To what extent did you and the patient discuss your respective roles? (Who is responsible for making decisions and who is responsible for what aspects of your care?) | Completely ☐ | Mostly ☐ | A little ☐ | Not discussed ☐ |
| 6. | To what extent did you explain treatment? | Very well ☐ | Well ☐ | Somewhat ☐ | Not at all ☐ |
| 7. | To what extent did you and the patient explore how manageable this (treatment) would be for the patient? We explored this … | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
| 8. | How well do you think you understood the patient today? | Very well ☐ | Well ☐ | Somewhat ☐ | Not at all ☐ |
| 9. | Regarding today’s problem, to what extent did you discuss personal or family issues that might be affecting your patient’s health? | Completely ☐ | Mostly ☐ | A little ☐ | Not at all ☐ |
The nine-item questionnaire has two versions. The patient version is shown in Table 17.2. The physician version is shown in Table 17.3. A total score of the patient version is the sum of responses to all items divided by 9 and ranges from 1 to 4. The nine-item questionnaires were coded so that a high score meant positive perceptions in order to enhance the ease of interpretation of the feedback to physicians, with high scores intuitively meaning better performance. For formative feedback to the physician, two displays were provided. First, the proportion of patients of the doctor who responded with the most positive rating was shown for each item in a bar graph, allowing each physician to see what aspect of patient-centered care he or she was better at or worse at. Second, the level of agreement between the patient and physician rating was shown for each item in a bar graph.
Descriptive Results
TABLE 17.4 Descriptive results for Patient Perception of Patient-Centeredness (PPPC): 14 items (N = 315)
| Variables | Range | Mean (Standard Deviation) |
|---|---|---|
| PPPC total score | 1–2.9 | 1.5 (0.37) |
| Patient perception that the illness experience has been explored | 1–3.3 | 1.2 (0.29) |
| Patient perception that the patient and physician found common ground | 1–3.3 | 1.7 (0.50) |
Table 17.4 shows the ranges, means, and standard deviations of the total 14-item PPPC and the two subscores for Components 1 and 3 as found in the study of 39 family physicians and 315 patients (Stewart et al. , 2000).
TABLE 17.5 Proportion of one physician’s patients who reported high ratings, with the explanation to the physician
|
|
| Q1 To what extent was your main problem(s) discussed today? |
| Q2 How satisfied were you with the discussion of your problem? |
| Q3 To what extent did the doctor listen to what you had to say? |
| Q4 To what extent did the doctor explain this problem to you? |
| Q5 To what extent did you and the doctor discuss your respective roles? (Who is responsible for making decisions and who is responsible for what aspects of your care?) |
| Q6 To what extent did the doctor explain treatment? |
| Q7 To what extent did the doctor explore how manageable this (treatment) would be for you? |
| Q8 How well do you think your doctor understood you today? |
| Q9 To what extent did the doctor discuss personal or family issues that might affect your health? |
| Summary : The vast majority of your patients were completely satisfied with the communication during the visit for Q1, Q2, Q4, and Q8. All eleven patients were completely satisfied regarding you listening to them during the visit – Congratulations! For the remaining questions, the minority were completely satisfied. The lowest percentage occurs for question 9 (20%). Although there may be legitimate reasons for not discussing personal or family issues that may affect health, this is an area that was not covered completely. Less than half of your patients were not completely satisfied with the extent of the discussion regarding respective roles (Q5) and the extent you explained treatment (Q6). This may have been due to something you and the patient either could not cover or only had time to discuss superficially. Also, 46% of patients did not feel that a complete discussion of how manageable treatment would be for them occurred. |
Table 17.5 shows the feedback on the proportion of patients giving the most positive rating for each item for one doctor. Physicians can see for which aspects of patient-centered care their patients perceive them positively.
TABLE 17.6 Level of agreement between the physician and that physician’s patients, with the explanation to the physician*
|
|
| The GREY (bottom) bar represents the percentage of patients for which physician and patient rating agreed. On average, you agreed with 64% of your patients. In general your level of agreement is fairly inconsistent. The highest level of agreement, 92%, occurred on Q8 (How well do you think your doctor understood you today?) with Q3 (To what extent did the doctor listen to what you had to say?) a close second. The lowest level of agreement, 23% occurred on Q9 (To what extent did the doctor discuss personal/family issues that may affect your health?). |
| Now looking at the BLACK (middle) bar, on average, you rated your communication lower than 18% of your patients. The main source of disagreement occurred on Q2 (How satisfied were you with the discussion of your problem?), for which you rated yourself lower than 31% of your patients. There could be many reasons for this: you and your patients may have interpreted the question in different ways, you may have underestimated the impact of what you did discuss, and/or you are not as confident in yourself regarding this area of communication during patient visits. There were no other notable disagreements in this direction. |
| Now looking at the WHITE (top) bar, on average, you rated your communication higher than 18% of your patients. Q7 (To what extent did the doctor explore how manageable this (treatment) would be for you?) and Q9 (To what extent did the doctor discuss personal or family issues that might affect your health?) both show fairly substantial disagreement in this direction (42% and 54%, respectively). |
Note: *These percentages are based on the responses of 13 patients.
Table 17.6 shows the level of agreement between one doctor and his or her patients, along with the written feedback provided to that physician.
Conclusion
This chapter shows the versatility of the patient perception measures as both research and education tools. The chapter has presented an overview of two questionnaire measures, showing their items, reliability and validity assessments, and their results. The two measures were the 14-item PPPC and the nine-item questionnaire, which has a patient version and a clinician version.