Contoh studlit

D. Riedl, G.
Schüßler The Influence of Docto r-Patient Communication on Health Outcomes
The Influence of Doctor-Patient Communication

on Health Outcomes: A Systematic Review
David Riedl1, Gerhard Schüßler1
Zeitschrift für Psychosomatische Medizin und Psychotherapie downloaded from www.vr-elibrary.de by 80.82.77.83 on April, 28 2018
Zusammenfassung
Der Einfluss der Arzt-Patient-Beziehung auf den Gesundheitszustand:
eine systematische Übersicht
Hintergrund: Für den Einfluss der Arzt-Patient-Beziehung sowie -kommunikation auf den
Gesundheitszustand ist eine weitere empirische Fundierung notwendig. Anhand der Unter-
scheidung zentraler Bereiche (bspw. Beziehungsqualität, Informationsvermittlung, Patienten-
edukation) können spezifische Ergebnisse beschrieben werden. Um die empirische Basis dieser
Annahmen zu überprüfen haben wir einen systematischen Review durchgeführt.
Methoden: In einem systematischen Review der Publikationen in Medline, Embase, Cochrane,
PsychLIt und Psyindex zwischen 2000 und 2015 wurden RCTs, kontrollierte und unkontrol-
lierte peer-reviewte Studien mit erwachsenen klinischen Stichproben identifiziert und analy-
siert. Studien mit psychiatrischen Stichproben, psychologischen oder psychotherapeutischen
Interventionen wurden ausgeschlossen.
For personal use only.
Ergebnisse: Siebzehn RCTs, siebzehn kontrollierte Studien sowie acht qualitative Studien er-
füllten alle Einschlusskriterien. Die generelle Studienqualität der RCTs und kontrollierten Stu-
dien war zufriedenstellend. 60% der Studien konnten einen positiven Effekt der Arzt-Patient-
Beziehung auf den Gesundheitszustand zeigen. Die Rolle von Informationsermittlung sowie
-vermittlung (Patientenedukation) wurde am häufigsten untersucht, wobei ein eindeutiger
positiver Effekt gefunden wurde. Auch die Kommunikationsfähigkeit führte zu verbesserten
Ergebnissen sowie zur verbesserten Unterstützung behandlungsbezogener Verhaltensweisen
und Emotionen. Zwei Studien, in denen eine ökonomische Evaluation mit eingeschlossen wur-
de, zeigten verringerte Kosten für das Gesundheitssystem.
Zusammenfassung: Im vorliegenden systematischen Review wurden überzeugende Effekte für
unterschiedliche Bereiche der Arzt-Patient-Beziehung sowie Aspekte der Kommunikation auf
verschiedene objektive und subjektive Gesundheitsparameter gefunden.
Z Psychosom Med Psychother 63/2017, 131-150
Keywords
Doctor-Patient Relationship – Doctor-Patient Communication – Patient Education – Com-
munication – Treatment-Related Behaviors
Summary
Objective: In order to evaluate the influence of the doctor-patient relationship and commu-
nication on healthcare outcomes, further reliable results are needed. More specific results can
be achieved depending on the differentiation of several domains (e.g., relationship, informa-
1 University Hospital of Medical Psychology, Medical University of Innsbruck, Austria.

Z Psychosom Med Psychother 63, 131–150, ISSN (Printausgabe) 1438-3608, ISSN (online) 2196-8349
© 2017 Vandenhoeck & Ruprecht GmbH & Co. KG, Göttingen
132 D. Riedl, G. Schüßler
tion gathering, or patient education). We conducted a systematic review including publications

from 2000 to 2015 to gather further empirical support.
Methods: A systematic review was carried out (with information drawn mainly from Medline,
Embase, Cochrane, PsychLit, and Psyndex) to identify RCTs as well as controlled and uncon-
trolled studies in clinical adult samples. Studies with psychiatric samples and psychological-
psychotherapeutic interventions were excluded.
Results: A total of 17 RCTs, 17 controlled studies, and 8 qualitative studies met the inclusion
criteria. The quality of the RCTs and controlled studies was satisfying. In the doctor-patient
relationship (building), 60% of the studies showed a positive effect on objective health param-
eters. Information gathering and provision (patient education) were the most investigated do-
mains with unequivocally positive effects. Communication (skills) showed improved results
and enabled treatment-related emotions and behavior. Two studies included an economical
evaluation with reduced healthcare costs.
Conclusions: A systematic review revealed different domains of the doctor-patient relation-
ship and communication with convincing effects regarding different objective and subjective
health outcomes.
1. Introduction
Throughout the history of medicine the doctor-patient relationship has been in the
center of treatment, however evidence for its effects is hard to prove. In the last com-
prehensive systematic meta-analysis up to the year 2000 Di Blasi et al. (2001) iden-
tified RCTs (N = 25) with 19 trials examining the effects of doctor patient-commu-
nication (half of them showed significant positive effects). The general effects of doc-
tor-patient communication and their relationship were described as “emotional and
cognitive care” mainly as “warm, friendly and reassuring manner” and “positive in-
formation about treatment.”
Di Blasi et al. (2001) confirmed the inconsistencies in definitions and measure-
ments and suggested necessary improvements (Epstein et al. 2005; Makoul, 2001).
The two aspects of emotional and cognitive care are dissolved in a set of communi-
cation and relationship tasks: relationship building (with empathy), gathering infor-
mation (with the patient’s perspective), share and provide information (patient ed-
ucation), reach agreement, decisions making (shared decision making). These rela-
tionship and communication tasks are geared to enable treatment-related behavior
and emotions for patients and relatives. Nowadays the economic aspect (“it pays
off”) has to be added. Since the last comprehensive review was published over 15
years ago and, taking into account the different aspects of doctor-patient communi-
cation and relationship, we updated the review with studies from 2000 up to 2015.
2. Methods
2.1. Search strategy
A systematic comprehensive search of databases between 2000 and 2015 was con-
ducted to identify studies eligible for a systematic review and synthesis of the litera-
Z Psychosom Med Psychother 63, ISSN (Printausgabe) 1438-3608, ISSN (online) 2196-8349
The Influence of Doctor-Patient Communication on Health Outcomes 133
ture. The search was carried out by using a large number of medical and psycholog-
ical electronic databases (MEDLINE, Cochrane Controlled Trials Register, PsycLIT,
Social Science Citation Index, Science Citation Index, EMBASE, PsycINFO, PSYN-
DEX, PsycARTICLES). A combination of 64 search terms was used within each data-
base. The search terms described different aspects of the patient-practitioner rela-
tionship, aspects of communication, contextual information, placebo effects, and dif-
ferent major diseases (e.g., cancer, diabetes, etc.). A manual search of the reference
lists from retrieved papers and previous related reviews was conducted to identify
further studies.
2.2. Selection criteria
Studies investigating verbal communication and interventions were included. We

used a broad approach, taking all studies into account which used randomized con-
trolled, controlled or uncontrolled designs2 in clinical adult samples. We excluded
studies examining treatment characteristics (e.g., different medication) and using
psychological-psychotherapeutic interventions or psychiatric samples.
2.3. Data extraction and statistical analysis

Data extraction followed a predefined stepwise strategy. Each step was individually
conducted by two researchers (GS and DR) and conflicting results were discussed
until consensus was reached. Irrelevant studies were excluded based on the studies’
title in a first step and based on their abstract in a second step. Finally, the full text
of all remaining studies was individually rated and cross-checked by both researchers
to be included in the review, if eligible.
A standardized data extraction form was used to collect data. The extraction of
the data comprised (1) reference information (author and date); (2) characteristics
of study population (number of patients and/or practitioners, disease of the popu-
lation) and study design (RCTs, controlled studies, or qualitative studies); (3) char-
acteristics of the intervention (type of intervention, aim, frequency, and duration of
the intervention); (4) main communication function; (5) characteristics of outcomes
(main outcome measures and results). The extracted data is presented as a descriptive
summary of the studies. Furthermore, an assessment of the studies’ quality was con-
ducted. Because of the high heterogeneity of intervention types and outcome vari-
ables among the studies, a quantitative meta-analysis of the extracted data was not
feasible.
We used a modified version of the checklist developed by Downs and Black (1998)
for the quality assessment. The checklist has been cited in over 300 reviews and is
usually used to evaluate randomized and non-randomized studies of healthcare in-
2 Since quantitative research strategies may not be able to evaluate the whole dimension of human
relationship and communication, we chose to include qualitative studies in the review as well.
terventions. We eliminated three of the original 27 items that were not applicable to
the type of studies included in our review.
The modified quality checklist finally consisted of 24 items that could be scored
with “Yes” (1), “No” (0), or “Unable to Determine” (0). The items were added up to
a total score ranging from 0–25 with higher values representing better study quality.
Because the subscales consisted of different numbers of items, mean values were
calculated to enable a comparison between the quality subscales. Five different qual-
ity criteria were assessed: quality of reporting (10 items), external validity (3 items),
internal validity–bias (6 items), internal validity–confounding (selection bias; 5
items), and power (1 item). Quality evaluation was independently conducted by two
reviewers, disagreement was resolved by reaching consensus. Interrater reliability was
assessed using Cohen’s kappa analysis on all items of the checklist. Values 0.6 were
defined as substantial, and values 0.8 as almost perfect (Landis & Koch 1977).
The checklist’s total score as well as its subscales were compared with study designs
using a one-way analysis of variance (ANOVA). Bonferroni Correction was used to
control the alpha error in multiple testing. The level of significance was taken as p < 0.05.
3. Results
The database search resulted in a total number of 1448 studies of which 269 were select-
ed as potentially relevant on the basis of their titles. After reviewing the abstracts of these
studies, a total of 31 articles were then assessed by a full-text review and among these,
14 articles fulfilled the inclusion criteria. The manual search of the reference lists of these
studies and previous reviews resulted in further 26 eligible studies. Finally, following the
full text evaluation, 40 articles with a total number of 27,499 patients were included in
the systematic review. The selection process is illustrated in figure 1.
Since design, sample sizes and content of the included studies were very hetero-
geneous, a calculation of a meaningful meta-analysis was not feasible. Studies were
therefore roughly divided in three groups based on the study design and consequent-
ly described based on the study content.
Qualitative studies comprised an average of 22 participants (range = 7–42), con-
trolled studies 1,194 participants (range = 3–8,140), and randomized controlled tri-
als included a mean number of 406 participants (range = 40–1,192). Interventions
in the included studies investigated a broad range of influential factors on health
outcomes and several studies contained more than one factor: the most frequent
topics were how to provide or gather information (n = 22), and to examine the
impact of relationship building (n = 19). About a fifth of the studies (n = 10) inves-
tigated the broad role of communication, including communication with patients or
relatives, and patients’ communication preferences. Four further studies examined
the role of treatment-related emotions.
About half of the studies were conducted longitudinally, with a mean duration of
eight months ranging from 0.5 to 36 months. The most frequently investigated clin-
ical disorders were cancer (n = 10), asthma (n = 8), and diabetes (n = 7).
Figure 1: Selection process flow chart
Regarding the quality assessment very good inter-rater reliability was found (Co-
hens Kappa = 0.9). The three study types differed significantly regarding the overall
study quality (F(2, 36) = 56.6, p < 0.001): RCTs showed the best overall quality with
a mean score of 20.0 (SD = 2.4; range: 17–25), controlled studies had an average
score of 14.4 (SD = 3.6; range = 8–21), and qualitative studies had the lowest quality
with a mean of 7.1 (SD = 1.1; range = 6–9). For controlled studies the more prob-
lematic areas were external validity and internal validity (confounding). For qualita-
tive studies all areas appeared to be problematic. For details in the studies’ quality
see table 1.
3.1. Relationship building
Several specific interventions to foster the doctor-patient relationship were investi-

gated. Participatory decision making (PCM) led to a better quality of the doctor–pa-
Table 1: Overview of Study Quality

RCT Controlled Qualitative p
Total Score (0–25) 20.9 14.3 7.2 < 0.001
Reporting (0–10) 8.3 6.5 4.2 < 0.001

External Validity (0–3) 3.0 1.8 0.8 < 0.001
Internal Validity: Bias (0–6) 4.8 3.7 2.2 < 0.001
Internal Validity: Confounding (0–5) 4.0 1.5 0.0 < 0.001
Power (0–1) 0.9 0.8 0.0 < 0.001
Note. Bonferroni correction was used to adjust p-value in post-hoc analysis.
tient relationship as perceived by the patient (Bieber et al. 2008). Furthermore, pa-
tients rated the physicians’ empathy higher after a specific empathy training, and phy-
sicians showed better abilities to decode the facial expression of emotions (Riess et
al. 2012).
The doctor-patient relationship was not only found to be the highest predictor of
patients’ satisfaction, but also to influence the subjective symptom burden (Little et
al. 2001). A better doctor-patient relationship was further associated with an im-
proved interpersonal exchange and with patient activation (Alexander et al. 2010),
positively influenced adherence (van Ganse et al. 2003), and led to a decrease in
patients’ uncertainty (Kuzari et al. 2013). A warm and empathic atmosphere during
treatments might even increase the placebo response (Kelley et al. 2009).
Regarding the direct influences of the doctor-patient relationship on the health
status contradicting evidence was presented: While Cooper et al. (2011) reported
more positive communication, and Zandbelt et al. (2007) observed improved doc-
tor-patient relationships to be associated with higher patient activation, both studies
found no direct influence on the health status. In contrast Auerbach et al. (2002)
realized a better doctor-patient relationship to be associated with improved disease-
related behavior and a better health status, and Wodskou et al. (2014) reported that
the physicians’ empathy correlated with a better health status of their patients. Fur-
thermore, Parchman et al. (2010) showed that participatory decision making led to
improved patient activation and consequently to better medication adherence and
an enhanced health status. In conclusion, three of five studies reported positive re-
sults (60%) and two studies negative results (40%) concerning the improvement of
health.
3.2. Information provision

Patients described uncertainty about their treatment and disease as a main issue (Ku-
zari et al. 2013). Informational needs were reduced by assessing the patients’ infor-
mation preferences, and fulfilled informational needs resulted in higher patient sat-
isfaction (Thoonen et al. 2002). Better provision of information and patient educa-
tion had a significant impact on the patients’ health status (Bhattacharyya et al. 2010;
Cabana et al. 2006; Casas et al. 2006; Clark et al. 2000; Smith et al. 2008; Sperl-Hillen
et al. 2011; Yilmaz & Akkaya 2002), on compliance (Bhattacharyya et al. 2010; Kostev
et al. 2014; van Ganse et al. 2003), and on quality of life (Aiarzaguena et al. 2007;
Dibbelt et al. 2010; Koff et al. 2009; Mackenzie et al. 2013; Martinez-Moragon et al.
2014). Moreover, better patient education did not result in more time spent with the
patients than usual care in the long run (Clark et al. 2000).
Yet, patients’ in-depth knowledge was sometimes seen as inappropriate, especially
by non-specialized doctors who did not feel comfortable with patients showing a
high level of expertise. These patients were therefore sometimes mistakenly consid-
ered as non-compliant by non-specialist doctors (Snow et al. 2013). Also, providing
more information was not always regarded as being a better approach. Skinner et al.
(2008) for example reported that the more the patients’ knowledge of their illness
increased the less the educators talked. Dibbelt et al. (2010) described that although
physicians showed good capabilities to establish emotional relationships during their
study they still lacked the ability to effectively inform and motivate their patients.
Especially in the field of cancer (Kimberlin et al. 2004; Kuzari et al. 2013; Macken-
zie et al. 2013; Wright et al. 2008) but also for other diseases (Wodskou et al. 2014),
high quality information and education were important for the patients themselves
as well as for their families and caregivers. This was appropriate not only for giving
support and for understanding the patients’ situation, but also for dealing with the
fatal consequences of the disease: Wright et al. (2008) for example described how
end-of-life discussions with advanced cancer patients and their families were able to
have a positive impact on the long-term bereavement adjustment after death.
3.3. Communication
Several studies showed that enhanced physicians’ communication skills can lead to
improved quality of life (Aiarzaguena et al. 2007). Physicians with better communi-
cation skills were more likely to inquire the patients’ concerns, encourage physical
activity and setting goals (Cabana et al. 2006), and were able to offer better emotional
support, which resulted in lower depression scores reported by the patients (Fujimori
et al. 2014). Cals et al. (2009) also found that better communication skills resulted
in less unnecessary prescription of antibiotics.
It was found that open communication was rated as the most important factor in
the patient-physician relationship by the patients (Schmidt et al. 2012) and that poor-
er communication might lead to an underestimation of the disease severity because
patients did not report important lifestyle issues (Moffat et al. 2006). Furthermore,
patient centered communication correlated with better emotional health and fewer
diagnostic tests and referrals (Stewart et al. 2000).
3.4. Enabling treatment-related emotions

Engaging patients in emotional work may not only facilitate coping with severe dis-
eases such as cancer and acceptance thereof, but also enable patients and physicians
to plan the best supportive care (Back et al. 2014). Specific training was found to
have a positive influence: if physicians were trained to detect psychological distress,
the patients’ anxiety decreased significantly (Girgis et al. 2009).
3.5. Enabling treatment-related behavior

Especially interventions targeting relationship and information provision are intend-

ed to improve the patients’ self-management. The willingness to take an active part
in his/her disease management is a major factor influencing adherence (van Ganse
et al. 2003). The physician’s empathy, good interpersonal exchange, and greater fair-
ness in the treatment process have led to higher levels of patient activation (Alexander
et al. 2012; Hojat et al. 2011), while improved patient activation itself has been asso-
ciated with higher medication adherence (Parchman et al. 2010). Several studies have
shown that appropriate patient education can help patients gain control over com-
plex diseases (Casas et al. 2006; Clark et al. 2000; Smith et al. 2008; Snow et al. 2013;
Sperl-Hillen et al. 2011), to feel more independent from medical advice (Snow et al.
2013), and leads to improved quality of life (Koff et al. 2009).
3.6. Economical evaluations

Two studies also included an economical evaluation: Zhang et al. (2009) reported
that end-of-life discussions with advanced cancer patients led to significantly lower
healthcare costs (950 $) in the last week of life and were associated with a higher
quality of dying. Koff et al. (2009) also found reduced healthcare costs if COPD pa-
tients were offered proactive integrated care compared to usual care, but the effect
was not statistically significant.
4. Discussion
The aim of this study was to investigate the influence of the doctor-patient relation-
ship on objective and subjective health outcomes. In their review Di Blasi et al. (2001)
showed that a modification of patient–practitioner relationships can have positive
effects on the patients’ health status. We followed this approach and conducted a
systematic review of peer-reviewed studies published between 2000 and 2015. The
aim of the study was to investigate high quality studies and to differentiate various
domains of doctor-patient relationship and communication.
4.1. Strengths and limitations

Of the initial 1,500 studies 39 studies fulfilled all inclusion criteria. The results of our
analysis showed convincing effects regarding the influence of the doctor-patient re-
lationship and communication on different objective and subjective parameters of
the patients’ health.
Regarding the rating of the studies’ qualities we had a very high inter-rater accor-
dance. While we found a good study quality across all RCTs and even controlled
studies, the quality of the included qualitative studies was comparably low. This may
be caused by the quality checklist we used in our study, which was not developed for
qualitative studies. Nevertheless, the included qualitative studies provided important
insights into influential factors for the physician-patient relationship. Not all aspects
of interpersonal relationships can be fully depicted by quantitative measures, which
is why we suggest not to neglect the findings of qualitative studies.
As mentioned, because of the high heterogeneity of intervention types and out-

come variables among the studies a statistical power meta-analysis (e.g., effect-size)
of the extracted data was not possible. An example of the different way of operation-
alization is how the concept of ’patient-doctor relationship’ was assessed in different
studies: while Kimberlin et al. (2004) used focus group interviews to identify aspects
of the doctor-patient relationship, other studies such as Little et al. (2001) or Alex-
ander et al. (2012) used self-administered questionnaires, which sometimes have
been previously validated and sometimes were pragmatically constructed for said
trial. We therefore follow the argument of Di Blasi et al. (2001): the results of a meta-
analysis would have been like comparing apples with oranges. As previously pointed
out by Salmon and Young (2005) and Young et al. (2011), the abundance of ap-
proaches and the lack of unifying theories hamper the comparability and general-
ization of studies in this field. Nevertheless, our systematic review showed a large
variety of studies investigating all kinds of different factors affecting the physician-
patient relationship and its influence on the patients’ health status. Although this did
not allow calculating overall effect sizes, the included studies were able to address
several fundamental topics which are of highest relevance in medicine. As most stud-
ies were longitudinal and covered enough patients to give the results good external
validity, the results may be generalized for other patients and other fields of medicine.
4.2. Different aspects of doctor-patient relationship and communication
Improved provision of information and adequate patient education did not only di-
rectly improve the patients’ health status, but also positively influenced compliance
and quality of life.
Contrary to a commonly expressed opinion, trained physicians did not need more
time in the interaction with their patients to accomplish improved information and
education results. Some studies even showed that the less time educators spent with
talking the better illness knowledge of the patients was observed. In the light of the
numerous positive influences of improved information provision and education on
the patients’ health status, there is sharing evidence how important specific and ap-
propriate communication training is, and not only for aspiring physicians. Dibbelt
et al. (2010) showed that although physicians might have good capabilities to estab-
lish emotional relationships, they often lacked the ability to effectively inform and
motivate patients.
When asked about their preferences, patients clearly rated open communication
as the most important aspect in their patient-physician relationship. Of course open
communication only works in a reliable relationship built on trust. Consequently,
means of relationship building are prerequisites for enabling satisfying education and
information provision. Insufficient relationship building may even have a deterio-
rating effect on health outcomes: Moffat et al. (2006) pointed out how insufficient
communication could even lead to underestimation of the severity of a disease and
therefore maltreatment, because patients did not feel secure enough to report im-
portant lifestyle issues.
Regardless of the unequivocal positive aspects of good patient education, Snow et

al. (2013) pointed out a very important problem in modern medicine: not all phy-
sicians are happy about well-informed patients. Their in-depth knowledge is some-
times even understood as inappropriate and doctors and nurses may get uncomfort-
able with a high level of patients’ expertise. Sometimes these patients are even con-
sidered as non-compliant by non-specialist doctors, because they tend to challenge
treatment decisions more often than less informed patients.
Several studies pointed out that adequate information and education were not
only important for the patients themselves, but also largely helped their families and
caregivers. This is not only true for giving support and for understanding the pa-
tients’ situation, but also for dealing with the fatal consequences of the disease:
Wright et al. (2008) described how end-of-life discussions with advanced cancer pa-
tients and their families had a positive impact on the long-term bereavement adjust-
ment after the patients’ death.

Concluding, our review presents further evidence for the importance of the doc-
tor-patient relationship and communication on different aspects of objective and
subjective health outcomes. Methodological high quality studies warrant further in-
vestigations of the different domains of the doctor-patient relationship.3
Conflict of Interest Disclosure
The authors report no conflict of interests.
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Corresponding Author: Univ.-Prof. Dr. Gerhard Schüßler, University Hospital of

Medical Psychology, Medical University of Innsbruck
E-Mail: gerhard.schuessler @tirol-kliniken.at

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D. Riedl, G.

Schüßler The Influence of Docto r-Patient Communication on Health Outcomes

The Influence of Doctor-Patient Communication

1 University Hospital of Medical Psychology, Medical University of Innsbruck, Austria.

tion gathering, or patient education). We conducted a systematic review including publications

2.2. Selection criteria

Studies investigating verbal communication and interventions were included. We

2.3. Data extraction and statistical analysis

Figure 1: Selection process flow chart

3.1. Relationship building

Several specific interventions to foster the doctor-patient relationship were investi-

Table 1: Overview of Study Quality

Total Score (0–25) 20.9 14.3 7.2 < 0.001

Reporting (0–10) 8.3 6.5 4.2 < 0.001

External Validity (0–3) 3.0 1.8 0.8 < 0.001

Internal Validity: Bias (0–6) 4.8 3.7 2.2 < 0.001

Internal Validity: Confounding (0–5) 4.0 1.5 0.0 < 0.001

Power (0–1) 0.9 0.8 0.0 < 0.001

Note. Bonferroni correction was used to adjust p-value in post-hoc analysis.

3.2. Information provision

3.4. Enabling treatment-related emotions

3.5. Enabling treatment-related behavior

Especially interventions targeting relationship and information provision are intend-

3.6. Economical evaluations

4.1. Strengths and limitations

As mentioned, because of the high heterogeneity of intervention types and out-

4.2. Different aspects of doctor-patient relationship and communication

Regardless of the unequivocal positive aspects of good patient education, Snow et

ment after the patients’ death.

Conflict of Interest Disclosure

The authors report no conflict of interests.

gramme in an out-patient clinic. Respir Med 96(7), 519–524.

Corresponding Author: Univ.-Prof. Dr. Gerhard Schüßler, University Hospital of

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