Biomedical subjects

Peter Franks

Publications and source records attributed to Peter Franks.

At least 19 recordsLinked to original sources

PubMed2007

Does providing cost-effectiveness information change coverage priorities for citizens acting as social decision makers?

Escalating costs have generated increasing calls for Medicare to use cost-effectiveness as one criterion in determining coverage decisions. Decision-makers in U.S. health care have largely assumed that the public will reject any explicit consideration of cost in coverage policy, but there has been little formal testing of that hypothesis. We tested this assumption in a pilot study in which groups of citizens learned about and discussed health care costs, CEA methods, and common ethical issues embedded in CEA. Participants received information about 14 conditions and treatments and were asked to prioritize them for funding by Medicare under assumptions of constrained resources. Contrary to prevailing assumptions, this diverse sample understood CEA, were largely open to its use, and changed their own funding priorities when given cost-effectiveness ratio information.

Adolescent↗

PubMed2007

Do personal and societal preferences differ by socio-demographic group?

For equity, preferences used in cost-effectiveness analyses (CEAs) should yield similar values for different groups with similar health states. We used data from the US 2000 Medical Expenditure Panel Survey, including socio-demographics, EQ-5D Index and EQ Visual Analog Scale (EQ VAS) scores, to examine whether EQ-5D Index (representing community preferences) and EQ VAS (representing personal preferences) scores differed systematically by socio-demographic group. Differences between EQ-5D Index and EQ VAS scores by socio-demographic group were small and mostly not statistically significant. These preliminary findings suggest that using the EQ-5D Index in CEAs may not contribute to socio-demographic inequities.

Adolescent↗

PubMed2006

Effects of a tailored interactive multimedia computer program on determinants of colorectal cancer screening: a randomized controlled pilot study in physician offices.

OBJECTIVE: Screening reduces colorectal cancer (CRC) mortality and is cost-effective, yet uptake is suboptimal. We developed and evaluated a personally tailored interactive multimedia computer program (IMCP) to encourage CRC screening. METHODS: Randomized controlled pilot trial evaluating the effects of the personally tailored CRC screening IMCP as compared with a non-tailored IMCP ("electronic leaflet") control. The IMCP was tailored to patient preference, self-efficacy, barriers, and readiness and deployed in busy primary care offices before scheduled doctor visits. Main outcomes were: CRC screening knowledge, self-efficacy, benefits and barriers, and stage of readiness. RESULTS: We enrolled 54 subjects; software glitches occurred in 5, leaving 49 subjects for analysis. In adjusted analyses, compared with control, the experimental group had a significant increase in CRC screening self-efficacy (p=0.049), a significantly greater likelihood of moving to a more advanced stage of readiness for screening (p=0.034), a trend toward fewer perceived barriers to screening (p=0.149), and no difference in perceived benefits or knowledge of screening. CONCLUSION: Our personally tailored IMCP was significantly more effective than control in bolstering CRC screening readiness and self-efficacy. PRACTICE IMPLICATIONS: If further streamlined, personally tailored IMCPs might be usefully deployed in busy primary care offices to improve uptake of CRC screening.

Algorithms↗

PubMed2006

Disparities in preventive procedures: comparisons of self-report and Medicare claims data.

BACKGROUND: Racial/ethnic disparities are assessed using either self-report or claims data. We compared these two data sources and examined contributors to discrepancies in estimates of disparities. METHODS: We analyzed self-report and matching claims data from Medicare Beneficiaries 65 and older who participated in the Medicare Current Beneficiary Survey, 1999-2002. Six preventive procedures were included: PSA testing, influenza vaccination, Pap smear testing, cholesterol testing, mammography, and colorectal cancer testing. We examined predictors of self-reports in the absence of claims and claims in the absence of self-reports. RESULTS: With the exception of PSA testing, racial/ethnic disparities in preventive procedures are generally larger when using Medicare claims than when using patients' self-report. Analyses adjusting for age, gender, income, educational level, health status, proxy response and supplemental insurance showed that minorities were more likely to self-report preventive procedures in the absence of claims. Adjusted odds ratios ranged from 1.07 (95% CI: 0.88 - 1.30) for PSA testing to 1.83 (95% CI: 1.46 - 2.30) for Pap smear testing. Rates of claims in the absence of self-report were low. Minorities were more likely to have PSA test claims in the absence of self-reports (1.55 95% CI: 1.17 - 2.06), but were less likely to have influenza vaccination claims in the absence of self-reports (0.69 95% CI: 0.51 - 0.93). CONCLUSION: These findings are consistent with either racial/ethnic reporting biases in receipt of preventive procedures or less efficient Medicare billing among providers with large minority practices.

Black or African American↗

PubMed2006

Gender and the burden of disease attributable to obesity.

OBJECTIVES: We estimated the burden of disease in the United States attributable to obesity by gender, with life expectancy, quality-adjusted life expectancy, years of life lost annually, and quality-adjusted life years lost annually as outcome measures. METHODS: We obtained burden of disease estimates for adults falling into the following body-mass index categories: normal weight (23 to <25), overweight (25 to <30), and obese (> or = 30). We analyzed the 2000 Medical Expenditure Panel Survey to obtain health-related quality-of-life scores and the 1990-1992 National Health Interview Survey linked to National Death Index data through the end of 1995 for mortality. RESULTS: Overweight men and women lost 270,000 and 1.8 million quality-adjusted life years, respectively, relative to their normal-weight counterparts. Obese men and women lost 1.9 million and 3.4 million quality-adjusted life years, respectively, per year. Much of the burden of disease among overweight and obese women arose from lower health-related quality of life and late life mortality. CONCLUSIONS: Relative to men, women suffer a disproportionate burden of disease attributable to overweight and obesity, mostly because of differences in health-related quality of life.

Adult↗

PubMed2006

Does the content of primary care visits differ by the racial composition of physicians' practices?

PURPOSE: The study compared the content of primary care visits between physicians with larger and smaller African American practices. METHODS: We compared the content of primary care adult visits between physicians with larger and smaller African American practices using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey 1997 to 2002. Larger African American practice (>14% of primary care visits by African Americans) was empirically defined to conform with previous studies. RESULTS: Larger African American practices comprised 24% of all practices but accounted for 80% of all visits by African American patients. In adjusted analyses, physicians with larger African American practices were less likely to refer patients to specialists (adjusted odds ratio 0.77; 95% confidence internal 0.61-0.98) and marginally less likely to perform rectal examinations (adjusted odds ratio 0.84; 95% confidence interval 0.56-1.00) but were more likely to schedule a return appointment (adjusted odds ratio 1.25; 95% confidence interval, 1.02-1.52). However, there were no other significant differences in the reported content of the office visits. Results were not altered when different cutoffs for larger African American practices were used or when obstetricians-gynecologists were excluded from the analyses. CONCLUSION: There are few differences in the content of office visits between physicians with larger and smaller African American practices.

Adult↗

PubMed2006

Association between obesity and patient satisfaction.

OBJECTIVE: To examine the relationship between BMI and patient satisfaction with health care providers using a nationally representative survey. RESEARCH METHODS AND PROCEDURES: This analysis examined the 9914 adult patients who completed the 2000 Medical Expenditure Panel Survey and had visited a health care provider within 12 months of the survey. Linear regression models were employed with patient satisfaction as the dependent variable. The patient satisfaction scale was based on ratings from five questions assessing the quality of provider interactions. The independent variable was BMI, with adjustments for the domains of demographics, social-economic status, health attitudes and behavior, health status, and health care use. BMI (weight in kilograms/square of height in meters) was classified as normal weight (18.5 to 24.9), overweight (25.0 to 29.9), or obese (>or=30.0). Hierarchical models were used to evaluate how each domain modified the BMI-satisfaction association. RESULTS: Obese patients reported significantly greater satisfaction with their health care providers than their normal-weight counterparts did (p < 0.05). There were no significant differences in satisfaction between normal-weight and overweight patients or between overweight and obese patients. The health status domain produced the largest modification in the BMI-satisfaction relationship. Examination of interaction effects revealed that the association between BMI and satisfaction was confined to older persons. DISCUSSION: In this nationally representative sample of individuals, obese persons were more satisfied than their normal-weight counterparts. This finding counters those of previous studies. Incomplete adjustments for health care use and insurance status may have led to those conclusions.

Adult↗

PubMed2006

Relative disutilities of 47 risk factors and conditions assessed with seven preference-based health status measures in a national U.S. sample: toward consistency in cost-effectiveness analyses.

BACKGROUND: Preference-based health measures yield summary scores that are compatible with cost-effectiveness analyses. There is limited comparative information, however, about how different measures weight health conditions in the U.S. population. METHODS: We examined data from 11,421 adults in the 2000 Medical Expenditure Panel Survey, a nationally representative sample of the U.S. general population, using information on sociodemographics (age, gender, race/ethnicity, income, and education), health status (EQ-5D, EQ-VAS, and SF-12), 4 risk factors (smoking, overweight, obesity, and lacking health insurance), and 43 conditions. From the EQ-5D, we derived summary scores using U.K. [EQ(UK)] and U.S. weights. From the SF-12 we derived SF-6D, and regression-predicted EQ-5D (U.S. and U.K. weights) and Health Utility Index scores. Each of the 7 preference measures was regressed on each of the 47 problems (risk factors and conditions) to determine the disutility associated with the problem, adjusting for socio-demographics. RESULTS: The adjusted disutilities averaged across the 47 problems for the 7 preference measures ranged from 0.059 for the SF-6D to 0.104 for the EQ(UK). Correlations between each of the measures of the adjusted disutilities ranged from 0.85-1.0. Standardization, using linear regression, attenuated between measure differences in disutilities. CONCLUSIONS: Absolute incremental cost-effectiveness analyses of a given problem would likely vary depending on the measure used, whereas the relative ordering of incremental cost-effectiveness analyses of a series of problems would likely be similar regardless of the measure chosen, as long as the same measure is used in each series of analyses. Absolute consistency across measures may be enhanced by standardization.

Adult↗

PubMed2006

Mammography self-report and mammography claims: racial, ethnic, and socioeconomic discrepancies among elderly women.

BACKGROUND: National self-report surveys show minimal racial disparity in mammography, whereas analyses of administrative data show large disparity. METHODS: Using the 1998-2002 Medicare Current Beneficiary Surveys, which contain participants' self-report and claims data, we developed multivariable adjusted models examining factors associated with self-reported mammography and self-reported mammography verified by billing records. RESULTS: No racial/ethnic disparities were found in self-reported mammography. Verified mammography, however, revealed significant disparities for race, education, income, insurance, and health status. CONCLUSIONS: Race, education, income, insurance, and health status are associated with a lower likelihood of self-reported mammography verified by the existence of claims data. These data caution against exclusive reliance on self-report survey data to assess disparity in mammography.

Aged↗

PubMed2006

Connoisseurs of care? Unannounced standardized patients' ratings of physicians.

BACKGROUND: Patient satisfaction surveys can be informative, but bias and poor response rates may limit their utility as stable measures of physician performance. Using unannounced standardized patients (SPs) may overcome some of these limitations because their experience and training make them able judges of physician behavior. OBJECTIVES: We sought to understand the reliability of unannounced SPs in rating primary care physicians when covertly presenting as real patients. STUDY DESIGN: Data from 2 studies (Patient Centered Communication [PCC]; Social Influences in Practice [SIP]) were included. For the PCC study, 5 SPs made 192 visits to 96 physicians; for the SIP study, 18 SPs made 292 visits to 146 physicians. SPs visits to physicians were randomized, thus avoiding mutual selection bias. Each SP rated 16 to 38 physicians on interpersonal skills (autonomy support: PCC, SIP), technical skills (information gathering: SIP-only), and overall satisfaction (SIP-only). We evaluated SP evaluation consistency (physician vs. total variance rho), and SPs' overall satisfaction with specific dimensions of physician performance. RESULTS: Scale reliability varied from 0.71 to 0.92. Physician rhos (95% confidence intervals) for autonomy support were 0.40 (0.22-0.58; PCC) and 0.30 (0.14-0.45; SIP); information gathering rho was 0.46 (0.33-0.59; SIP). Overall SP satisfaction rho was 0.47 (0.34-0.60; SIP). SPs varied significantly in adjusted overall satisfaction levels, but not other dimensions. CONCLUSIONS: These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings.

Clinical Competence↗

PubMed2006

Do patient requests for antidepressants enhance or hinder physicians' evaluation of depression? A randomized controlled trial.

OBJECTIVE: We sought to ascertain whether patients' requests for antidepressants affect visit duration or history taking by primary care physicians (PCPs) for patients with depressive symptoms and a coexisting musculoskeletal disorder and to determine whether more thorough history taking is associated with diagnostic accuracy or with provision of minimally acceptable initial care for major depression. DESIGN: This was a randomized trial using standardized patients (SPs). Six roles involved 2 conditions (major depression and adjustment disorder, both with coexisting musculoskeletal conditions) and 3 patient request types (brand-specific, general, or none). We conducted the study in 152 PCP offices in Northern California and Rochester, New York. Physicians were assigned randomly to see 2 SPs with depression/wrist pain or adjustment disorder/back pain. MAIN OUTCOME MEASURES: Physician history-taking for depression and the musculoskeletal condition; depression diagnosis in the medical record; antidepressant prescriptions/samples; referral/follow-up recommendations; visit duration; and provision of minimally acceptable initial depression care. RESULTS: General antidepressant requests were associated with more depression history-taking (Adjusted Parameter Estimate = 0.80 more questions of 10 (95% confidence interval = 0.31-1.29, P < 0.001); brand-specific requests were marginally associated with more depression history-taking (Adjusted Parameter Estimate = 0.45, 95% confidence interval = -0.04-0.93, P = 0.07). Antidepressant medication requests were not related to musculo-skeletal question asking (P > 0.3) or visit length (P > 0.8). Depression history taking was directly associated with the likelihood of a chart diagnosis of depression and the provision of minimally acceptable initial depression care. CONCLUSION: General antidepressant requests increase depression history taking, including screening for suicide. Patients' requests for medication do not appear to short-circuit history taking for depression or distract the physician's attention from coexisting musculoskeletal conditions.

Adjustment Disorders↗

PubMed2006

Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients.

Objective. To examine the prevalence, predictors, and consequences of physician detection of unannounced standardized patients (SPs) in a study of the impact of direct-to-consumer advertising on treatment for depression. Data Sources. Eighteen trained SPs were randomly assigned to conduct 298 unannounced audio-recorded visits with 152 primary care physicians in three U.S. cities between May 2003 and May 2004. Study Design. Randomized controlled trial using SPs. SPs portrayed six roles, created by crossing two clinical conditions (major depression or adjustment disorder) with three medication request scripts (brand-specific request, general request for an antidepressant, or no request). Data Collection. Within 2 weeks following the visit, physicians completed a form asking whether they "suspected" conducting an office visit with an SP during the past 2 weeks; 296 (99 percent) detection forms were returned. Physicians provided contextual data, a Clinician Background Questionnaire. SPs filled in a Standardized Patient Reporting Form for each visit and returned all written prescriptions and medication samples to the laboratory. Principal Findings. Depending on the definition, detection rates ranged from 5 percent (unambiguous detection) to 23.6 percent (any degree of suspicion) of SP visits. In 12.8 percent of encounters, physicians accurately detected the SP before or during the visit but they only rarely believed their suspicions affected their clinical behavior. In random effects logistic regression analyses controlling for role, actor, physician, and practice factors, suspected visits occurred less frequently in HMO settings than in solo practice settings (p<.05). Physicians more frequently referred SPs to mental health professionals when visits aroused high suspicion (p<.05). Conclusions. Trained actors portrayed patient roles conveying mood disorders at low levels of detection. There was some evidence for differential treatment of detected standardized patients by physicians with regard to referrals but not antidepressant prescribing or follow-up recommendations. Systematic assessment of detection is recommended when SPs are used in studies of clinical process and quality of care.

Adjustment Disorders↗

PubMed2006

What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms.

BACKGROUND: Referral from primary care to the mental health specialty sector is important but poorly understood. OBJECTIVE: Identify physician characteristics influencing mental health referral. DESIGN: Randomized controlled trial using Standardized Patients (SPs). SETTING: Offices of primary care physicians in 3 cities. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors. INTERVENTION: Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. MEASUREMENTS: Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire. RESULTS: Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent > or =10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92). LIMITATION: The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients. CONCLUSIONS: Controlling for patient and health system factors, physicians' therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care.

Adult↗

PubMed2006

Discharges against medical advice: are race/ethnicity predictors?

BACKGROUND: Prior literature suggests that blacks are more likely to be discharged against medical advice (DAMA). OBJECTIVE: We examined whether DAMA from general hospitals varies by race/ethnicity and whether this variation is explained by individual and hospital factors. DESIGN, SUBJECTS, AND MEASUREMENTS: We conducted cross-sectional analyses of 1998 to 2000 hospital discharge data, linked to the American Hospital Association data, on adults admitted for acute general hospital care in California, Florida, and New York. A series of hierarchical logistic regression analyses explored factors associated with DAMA, initially adjusting for age and gender, then sequentially adding adjustment for comorbidities, individual socio-economic factors, and finally hospital characteristics. RESULTS: Compared with whites, blacks had a 2-fold higher age-gender adjusted odds of DAMA, a risk that progressively diminished with increasing adjustment (final adjusted odds ratio [OR] = 0.95, 95% confidence interval [CI] = 0.91, 1.00). While Hispanics had an increased risk of DAMA in age-gender-adjusted analyses, the final model revealed a protective effect (adjusted OR = 0.66, 95% CI = 0.62, 0.70), similar to that observed for Asians. CONCLUSIONS: Disparities in DAMA affecting minority patients in general hospitals are largely accounted for by individual and hospital socio-economic factors. The absence of any adjusted disparity affecting blacks, and the protective effect observed for Hispanics and other minorities suggest that individual discrimination and poor communication are not primary determinants of DAMA, but where patients are admitted does contribute to disparities in DAMA.

Adolescent↗

PubMed2005

The burden of disease associated with being African-American in the United States and the contribution of socio-economic status.

The burden of disease associated with being African-American in the US, and the contribution of socio-economic status (SES) to that burden have not been quantified. We derived burden of disease estimates for African-Americans and whites by age group, with and without adjustment for SES (income and education). We used (1) EQ-5D Index scores from the 2000 US Medical Expenditure Panel Survey to derive quality-adjusted life year (QALY) compatible estimates of health-related quality of life (HRQL); (2) 1990-1992 US National Health Interview Survey data linked to National Death Index data through 1995 to derive mortality risks; and (3) 2000 US mortality data from the National Center for Health Statistics to derive current mortality estimates for the US population. We found that relative to whites, African-Americans suffer 67,000 more deaths annually, resulting in 2.2 million years of life lost, and 1.1 million years after SES adjustment. Total QALYs lost (HRQL and mortality) dropped from 2.3 million to 902,000 after SES adjustment. SES differences between African-Americans and whites appear to explain all the HRQL disparity but only half the mortality disparity. Better understanding of the disparate effects of SES may inform interventions to address health disparities adversely affecting African-Americans.

Adult↗

PubMed2005

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators.

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Adult↗

PubMed2005

Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.

CONTEXT: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. OBJECTIVE: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. DESIGN: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). SETTING: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. INTERVENTIONS: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. MAIN OUTCOME MEASURES: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. RESULTS: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). CONCLUSIONS: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

Adjustment Disorders↗

PubMed2005

Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

Communication↗