We know that patients in our sample perceive the use of PVEs and option-lists, as opposed to recommendations, as inviting choice. But does the use of certain practices tend to lead to higher levels of patient satisfaction? This issue is addressed in the analyses in Table 14, which show the bivariate links between patient satisfaction and the use of different interactional practices. Patient satisfaction was measured through the MISS-21 scale and through two key subcomponents of this scale: the rapport and Distress Relief subscales. The mean scores for consultations containing different practices were compared.
These analyses show that there is no significant difference in overall patient satisfaction, no matter which of the different forms of practice are employed in consultations. Scores on the rapport subscale also do not differ depending on decisional practice employed. However, there is a significant difference (albeit at the 0.1 level) between consultations with PVEs and those without PVEs on the Distress Relief subscale. TABLE 13 Multivariate predictors of decisional practice (odds ratios of consultation containing at least one PVE or option-list)
Variable
Specification
1 (n = 90) 2 (n = 132)
OR 95% CI OR 95% CI
Clinic type (ref = specialist)
General 0.18 0.04 to 0.84 0.42 0.13 to 1.37
Symptoms (ref = completely unexplained)
Completely explained 0.24 0.04 to 1.37 0.34* 0.11 to 1.08
Partly explained 0.18 0.02 to 1.31 0.41 0.11 to 1.58
Perceived choice (ref = doctor no, patient yes)
Agree: choice 5.03** 1.16 to 21.89 5.05*** 1.73 to 14.68
Agree: no choice 1.15 0.16 to 8.24 0.82 0.21 to 3.22
Doctor yes, patient no 0.65 0.13 to 3.22 1.46 0.40 to 5.32
First appointment (ref = follow-up)
First 0.40 0.10 to 1.55 – – Certainty 1.47** 1.07 to 2.01 1.23* 0.97 to 1.5 Age 0.99 0.95 to 1.03 0.99 0.96 to 1.01 Physical health PCS 1.04** 1.00 to 1.08 – – ****p ≤ 0.001, ***p ≤ 0.01, **p ≤ 0.05, *p ≤ 0.1.
–, not applicable; CI, confidence interval; OR, odds ratio; ref, reference category. Note
It could be argued that this low significance level finding does not constitute a strong enough link between this aspect of satisfaction and decisional practice to justify further investigation and that, therefore, we find no evidence for a link between decisional practice and any aspect of patient satisfaction (as measured by the MISS-21). However, for completeness, we again conducted two further multivariate analyses to investigate. Taking scores on the Distress Relief subscale as the dependent variable in a linear regression (using generalised estimating equations to account for the clustered data), we entered all relevant demographic and clinical variables showing an association (at the 0.2 level) with the Distress Relief subscale into our models, alongside the PVE binary variable, as independent variables.
We do not show the results of all bivariate analyses used to identify the potential predictors to include in these models (because the aim of this study is not to identify predictors of patient satisfaction), but all demographic and clinical factors covered in Chapters 5 and 6 were examined for associations with the Distress Relief subscale using chi-squared tests, t-tests and one-way ANOVAs, as appropriate. If variables are not included in these models, then this indicates that they did not show p-values of < 0.2 in associations with the Distress Relief subscale. Specification 1 included all relevant variables, whereas specification 2 excluded independent variables with > 5% missing values. The results of these analyses can be seen in Table 15. The individual neurologist variable was not included in either model because it led to overfitting. The mental health composite score (MCS) is computed from the SF-12 questionnaire data. The range is from 0 to 100 (lowest to highest level of mental health as measured on the SF-12).
Table 15 shows that the Distress Relief component of patient satisfaction is related to a variety of demographic factors. Patients in Sheffield report higher levels of satisfaction, as do patients who are unemployed. There is some evidence (in specification 2) that white British patients and patients about whom neurologists reported having higher levels of diagnostic certainty have higher scores on the Distress Relief patient satisfaction subscale. However, the weak link between the Distress Relief subscale and interactional practice identified in bivariate analyses does not remain significant when other factors are controlled. In other words, there is no evidence here that even this aspect of patient satisfaction is linked to decisional practice.
Clinician numbers were too small to conduct meaningful tests for significant differences at the individual level. However, it is intriguing to note that the Sheffield neurologist who routinely used PVEs (they occurred in all 19 of the recordings they contributed to the sample, see Chapter 6) scored the highest on overall satisfaction and on the two subscales, with a notably higher score for Distress Relief than the other neurologists in the sample. By contrast, the Glasgow neurologist who most commonly used recommendations (see Chapter 6) scored below average on overall satisfaction and on each of the subscales.
TABLE 14 Distribution of MISS-21 and subscale scores across consultations containing different decisional practices, mean (SD) Patient satisfaction measure Form of practice All ≥1 PVE ≥1 option-list ≥1 PVE or option-list No PVE or option-list (only recommendations) MISS21 (n = 120) 100.0 (11.5) 99.8 (10.7) 99.7 (11.5) 97.5 (9.5) 98.4 (10.7) Rapport (n = 120) 0.11 (1.01) 0.03 (0.99) 0.08 (1.01) –0.08 (0.92) 0.01 (0.97) Distress Relief (n = 120) 0.13* (0.90) 0.14 (0.86) 0.11 (0.89) –0.15 (0.87) 0.00 (0.88) ****p ≤ 0.001, ***p ≤ 0.01, **p ≤ 0.05, *p ≤ 0.1. Note
Statistical tests show comparisons between ≥ 1 PVE and no PVE; ≥ 1option-list and no option-list; and ≥ 1 PVE or option-list and no PVE or option-list.
DOI: 10.3310/hsdr06340 HEALTH SERVICES AND DELIVERY RESEARCH 2018 VOL. 6 NO. 34
© Queen’s Printer and Controller of HMSO 2018. This work was produced by Reuber et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Conclusion
It appears that patients and neurologists share a common understanding of what the use of PVEs, option-lists and recommendations signifies in terms of giving patients choice. Consultations with PVEs and option-lists are much more likely than consultations with only recommendations to be described as involving choice by both doctors and patients, even after controlling for other relevant variables. This concurrence between neurologists and patients is very important methodologically because it provides evidence that our conceptual focus on option-lists and PVEs as opposed to recommendations is justified, and that our methodological processes are valid.
This is also an important substantive finding with implications for practice because it appears to indicate that neurologists and patients both understand the concept of patient choice in a similar way and that, crucially, practices matter for the perception of choice. Although we cannot claim to have controlled for all potentially confounding and mediating variables in our modelling, we have controlled for a variety of different factors, and consultations with option-lists and PVEs remain significantly more likely to be understood by patients and doctors as involving choice. Thus, if clinicians want patients to leave consultations with the impression that choice was offered, it seems likely that they should be employing option-lists and PVEs rather than just recommendations. We consider the implications of this finding further in Chapter 11.
To turn to our analysis of patient satisfaction, there is little evidence in our data set that the use of certain interactional practices is linked to patient satisfaction with their interaction with the neurologist (at least as measured by the MISS-21). Overall patient satisfaction and scores on the patient–doctor rapport subscale TABLE 15 Multivariate predictors of Distress Relief subscale of the MISS-21
Variable Specification 1 (n = 100) 2 (n = 117) B 95% CI B 95% CI Site Glasgow –0.44** –0.84 to –0.03 –0.57*** –0.90 to –0.23
Gender (ref = male)
Female –0.44 –0.09 to 0.58 0.24 –0.07 to 0.55
Employment status (unemployed)
Employed/in education –0.33** –0.62 to –0.03 –0.29** –0.56 to –0.01
Ethnicity (ref = other)
White British 0.46 –0.17 to 1.08 0.58* –0.07 to 1.24
Age 0.00 –0.01 to 0.01 0.01 –0.01 to 0.02
Symptoms (ref = completely unexplained)
Completely explained 0.29 –0.21 to 0.79 0.30 –0.16 to 0.77 Partly explained –0.13 –0.74 to 0.48 –0.07 –0.60 to 0.45 Certainty 0.04 –0.03 to 0.11 0.06* –0.01 to 0.13 Mental health (MCS) 0.01 0.00 to 0.02 – – PVE PVE 0.19 –0.17 to 0.55 –0.03 –0.35 to 0.30 ****p ≤ 0.001, ***p ≤ 0.01, **p ≤ 0.05, *p ≤ 0.1.
are no higher when PVEs or offers are used and, although bivariate findings suggested scores on the Distress Relief dimension of the MISS-21 may be higher when PVEs are used, this finding was not replicated when other clinical and demographic factors were controlled for. It is necessary to be cautious with our conclusions here because the MISS-21 has not been validated for use in neurology secondary care; however, we can say that there is no evidence here to suggest that decisional practice is linked to patient satisfaction as measured through the MISS-21.
It is worth noting that Sheffield neurologists, who used a greater number of option-lists and PVEs than their counterparts in Glasgow, also scored more highly on patient satisfaction, as did the neurologist who stood out for using PVEs in every consultation. This suggests that, although the use of the more participatory approaches to decision-making may not in itself be linked to higher levels of patient satisfaction, it may form part of a larger ‘approach’ to the consultation that patients do value. This warrants further exploration in future research.
It is also important to note that our finding of no significant relationship between decisional practice and patient satisfaction contrasts with Opel et al.’s43finding that doctors’ use of what they call ‘participatory
formats’ was positively associated with parents’ (who were attending with their young children) higher ratings of the ‘experience’, which, despite being differently measured, might act as a proxy for satisfaction. However, the two settings are rather different (neurology clinics in the UK vs. primary care paediatric clinics in the USA), as are the measures used.
In brief, we have shown that option-lists and PVEs are perceived as offering choice by both neurologists and patients. However, we found no evidence to suggest that the use of these practices is associated with significantly greater levels of patient satisfaction with the consultation (as measured by the MISS-21).
DOI: 10.3310/hsdr06340 HEALTH SERVICES AND DELIVERY RESEARCH 2018 VOL. 6 NO. 34
© Queen’s Printer and Controller of HMSO 2018. This work was produced by Reuber et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Chapter 8 Outcomes II: interactional consequences
of the use of different decisional practices
Introduction
In Chapter 7 we focused on outcomes that are external to the consultation: participants’ self-reported
perception of whether or not choice was offered and patients’ satisfaction with the just-recorded consultation. In the analyses presented in this chapter, we focus on the consequences, within the consultations themselves, of the use of the different interactional practices. There are two main ways in which we address this issue. First, we examine the immediate responses to the different forms of practice to explore how people tend to respond to each type. Second, we examine which of the methods is most likely to end up with the proffered course of action being agreed on at the end of the decision-making process.